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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgeryofheadnecOOIane 


THE  SURGERY 


OF  THE 


HEAD  AND  NECK 


BY 


LEVI   COOPER   LANE, 

A.  M.,  M.  D.  (Berol.),  M.  R.  C  S.  ENG.,  LL.D.,  PROFESSOR  OF 
SURGERY  IN  COOPER  MEDICAL  COLLEGE, 
SAN  FRANCISCO 


Second  edition 


PHILADELPHIA, 
P.  BLAKISTON,  SON  &  COMPANY, 

IOI2  WALNUT  STREET, 


-      -     L 


EnttTPfl  acfonliiiy;  to  act  of  Congress  in  the  year  1890 

BY 

LEVI  COOPER  LANE,   A.   M..   31.   I). 

In  the  office  of  the  Librarian  of  Congress,  at  Washington,   D.   C. 
All  rights  reserved. 


It  has  been  the  custom  of  authors  in  separating  from  their 

books  to  say  a  parting  word  to  them;  this,  by  some,  has  been  a 

dedication  to  a  father,  brother  or  friend,  and  in  one  case  to  the 

Author  of  Nature.     Horace  warns  his  of  coming  abuse  and  final 

neglect;  Martial  hints  to  his  scroll  that  it  may  serve  the  base 

use  of  wrapping  fish,  or  the  worse  one  of  becoming  a  flaming 

festoon  to  illuminate  and  torture  the  criminal;  but  Ovid,  more 

ambitious  and  hopeful,  announced  in  advance  the  salutations  of 

immortality  with  which  the  coming  years  would  greet  his  Meta- 

morpljoses;  but  the   medical  writer  of  to-day,  warned    by  the 

fortune  of  his  cotemporaries,  may  prudently  contract  the  horizon 

of  his  expectation,  and  reckon  on  but  a  brief  life  for  his  book. 

He   who   thinks   otherwise,  reckons   ill   with    Futurity.      Thus 

warned,  with   limited  hope,  should  a  few  years  of  existence  be 

granted  to  the  following  pages,  the  writer's   expectations  will  he 

fully  realized. 

Levi  Cooper  Lane. 


CONTENTS. 


CHAPTER  I. 

SURGERY   OF   THE   SCALP. 
SURGICAL  ANATOMY  OF  THE  SCALP. 

CHAPTEE  II. 

GENERAL  CLASSIFICATION  OF  THE 
AFFECTIONS  OF  THE  SCALP,  FOL- 
LOWED BY  A  CONSIDERATION 
OF  INFLAMMATION  AND  OTHER 
MATTERS  WITHIN  THE  SPHERE 
OF  GENERAL  SURGICAL  PA- 
THOLOGY. 


u 


CHAPTER  III. 

"WOUNDS   OF   THE  SCALP. 

Incised 51 

Lacerated 60 

Contusion  of  the  scalp 65 

Gunshot  wounds 72 

Scalp  and  skull 76 

Treatment 78 

Gangrene 82 

Ulceration 85 

Hypertrophy 88 

Atrophy 89 

Tumors 89 

Warts 91 

Cystoma 93 

Lipoma 99 

Angioma 103 

Vascular  growths 114 

Infantile  sanguineous  tumor  .    .    .  119 

Pigment  marks 120 

Malignant  growths 121 

Epithelioma 131 

Treatment 135 

Carcinoma 139 

Treatment IM 

Pneumatocephalus 145 

Pericranium  and  its  affections.    .    .  147 

Wounds 147 

Cranial  Periostitis 148 

CHAPTER  IV 

CRANIUM. 


Traumatic  lesions  of  the  cranium  . 
Incised  Wounds         "  " 


PAGE 

PAGE      Fracture  of  the  Cranium 159 

7  Treatment 166 

7       Gunshot  wounds  of  the  cranium.    .  172 

Treatment 179 

Trephination 185 

CHAPTER  V. 

MENINGES    OF    THE    BRAIN. 

Surgical  affections  of  the  membranes 

of  the  hrain 209 

External    pachymeningitis    of 

puerperal  origin 215 

Tumors  of  the  dura  mater    .    .    216 

Epithelioma 218 

Osteoma 218 

Psammoma .    219 

Parasitic  tumors 219 

Constitutional  tumors   ....    219 

Tubercle 220 

Syphiloma 220 

Etfects  of  meningeal  tumors  .  220 
Treatment  of  meningeal  tumors  221 
Concussion  of  the  brain    .    .    .    223 

Diagnosis 230 

Prognosis 231 

Treatment        232 

Compression  of  the  brain  .   .    .    234 

Diagnosis 238 

Prognosis 239 

Treatment 240 

General  consideration  of 
the  conditions  which  fa- 
vor    or    contraindicate 

trephining 242 

Contusion  of  the  brain  .    .    .    .    245 

Prognosis 247 

Treatment 248 

•CHAPTEE  VI. 

Encephalitis,  or  Inflammation 

OF  THE  brain 250 

Causes 250 

Symptoms 252 

Diagnosis 255 

Treatment 257 

Tumors 261 

Syphiloma 262 

Symptoms  of  intra-cranial   tu- 

153  "^mor 263 

157  Treatment        26T 

(V) 


VI 


CONTKNTS. 


PA<:e 
Meningocele  iind  eiieepluilocele  270 

Treatment 272 

Hj'dioeephalus 272 

Treatnienl 275 

3Iicroccphalus 278 

CHAPTEE  VII. 

Surgery  ok  thk  External  Ear..  285 
Defects  and  affections  of  the  ex- 
ternal ear 288 

Wounds  of  the  external  ear.    .     290 

Treatment 291 

Othaematonia 291 

Treatment 293 

Adherent  pinna 296 

Eents,  fissures,  and  other  de- 
fects in  which  there  is  a  loss 

of  structure 297 

Affections  of  the  auditory  canal  298 
Treatment  ....'...  299 
Occlusion  of  the  auditory  canal  300 
Polypus  in  the  auditory  canal.  301 
Occlusion  of  the  canal  by  ceru- 
men or  foreign  bodies.  .  .  .  301 
H.emorrhage  from  the  auditory 

passage 306 

Mastoid  cavity 308 

Emphysema — pneumatocepha- 

lus." 311 

Treatment 312 

CHAPTEE  VIII. 

Surgery  of  the  Frontal  Eegion  315 

Erontal  region 315 

Acne 315 

Treatment 315 

Frontal  sinus 318 

Trephining,    how    done    over 
frontal  sinus 323 

CHAPTEE  IX. 

No!<E  AND  Nasal  Passages  .    .    .  325 

Defects 327 

Injury 328 

Fracture  of  the  nas^l  bones.    .  329 

Treatment 330 

Growths  affecting  the  external 

surface  of  the  nose.    ....  33-i 

Angioma 336 

''Treatment 337 

Lupus 338 

Treatment 339 

Lupus  rodens,  or  rodent  ulcer.  341 

Treatment 342 

Nostrils  and  Their  Diseases  .  343 

Narrowness 343 

Deflection  of  the  nasal  septum.  340 

Treatment 347 

Purulent  Tumor 34« 

Treatment 349 

Necrosis  of  the  osseous  septum.  351 


PAGE 

Obstruction  of  the  nasal  passages  351 
Kasal  polypus 352 

Symptoms 353 

Treatment 355 

Fibrous  polypus 360 

Treatment 364 

Hypertrophy  of  the  nasal  mu- 
cous membrane 370 

Bleeding  from  the  nose.   .    .    .    371 

Treatment 376 

Foreign   bodies    in   the    nasal 

passages 381 

Pai'asites  in  the  nasal  passages.  382 
Ozicna,  or  nasal  catarrh   .    .    .    383 

Treatment 385 

CHAPTEE  X. 

Maxillary  Sinus,   or   Antrum 

OF  Highmore 391 

Abscess  of  the  maxillary  siiuis.  393 

Treatment 395 

Fistula  of  the  antrum  ....    396 

Treatment 379 

Cysts  in  the  antrum 397 

Treatment 398 

Tumor  of  the  maxillary  sinus  .  398 
Perforation  of  the  nasal  septum  400 
Nasal  deformity  and  means  em- 
ployed for  its  relief.  ....    402 

Ehinoplasty 406 

Partial  nasal  repair 420 

Alar  margin  defect  of  .    .    .    ,    421 
Defects  from  the  loss  of  the  side 
of  the   nose,   including    the 
alar  margin 421 

CHAPTEE  XI. 

The  Elements  of  Plastic  Sur- 
gery-  427 

The   first   method,   or  that   of 
immediate  adduction.    .    .    .    430 

The  second  method 433 

The  third  method 441 

Other  methods 445 

Thiersch's  method  of  cutaneous 
transplantation 449 

CHAPTEE  XII. 

Surgical     Affections    of    the 

Eyebrows  and  Eyelids    .    .    .  455 

Eyebrow 455 

Eyelid 459 

Wounds  of  the  eyelids  ....  468 

Erysipelas 467 

Burns 468 

Emphysema 469 

CHAPTER   XIII. 

Diseases  of  the  Eyelid  ....    471 

Hordeolum,  acne  ciliaris,  or  .sty  471 

Treatment 471 


CONTENTS. 


vn 


PAGE 

'Chalazion,  otherwise  known  as 
tarsal,  gelatinous  or  fibrous 
tumor  of  the  eyelid    ....    471 

Treatment 472 

Palpebral  deformities    ....    473 

Treatment 473 

Ankyloblepharon,  blepharophi- 
mosis,  or  narrowness  of  the 

palpebral  opening 475 

Treatment 475 

Symblepharon,  or  bulbo-palpe- 

bral  union 476 

Treatment 477 

Ectropion 478 

Entropion 486 

Congenital    deformity    of    the 

eyelid 489 

Treatment 489 

Epicanthus 490 

Treatment 491 

Blepharoplasty 491 

Tumors  arising  from  the  orbital 

wall 494 

Treatment 495 

Tumors  originating  within  the 

orbit 496 

I^oreign  bodies  in  the  eye.    .    .    500 
Treatment 501 

CHAPTEE  XIY. 

Surgery  of  the  Malar  and  Par- 

OTIBEAN  KeGIONS    OF    THE  EaCE    503 

Wounds  of  the  cheek  and  side 

of  the  face 504 

Scrofulous  ulcer 508 

Treatment 509 

Parotidean  region  of  the  face  .    509 
Inflammatory  affections  of  the 
parotid  gland:  parotitis    .    .    513 

Treatment 514 

Parotidean  growths 515 

-Salivary  concretion 516 

Treatment 517 

Benign  tumors 517 

Angioma 517 

Treatment 518 

Malignant  growths  of  the  par- 
otid gland 521 

Epithelioma 522 

Carcinoma 523 

Treatment  of  malignant  tumors 

of  the  parotis 523 

Parotidean  fistula 528 

CHAPTEPv  XY. 

Maxilla  Stjperior 533 

Fracture  .........    533 

Eesection  of  the  upper  jaw  .    .    536 


CHAPTEE  XVI.  PAGE 

Mouth  and  Oral  Cavity.   .   .    .    544 

Lips 544 

Treatment  of  partial  or  com- 
plete atresia  of  the  mouth.   .    548 

Macrostoma 550 

Treatment 552 

Deviation  of  the  oral  opening .    552 

Labial  hypertrophy 553 

Treatment 553 

Labial  ectropion 554 

Hare-lip,  cleft-lip,  labium  lep- 

orinum 555 

Operation 566 

Operation  on  uncomplicated 
double  hare-lip 575 

CHAPTEE  XVII. 

Labial  Growths 585 

Treatment 586 

Labial  cystoma 589 

Labial  cancer 590 

Commencement  and  course  591 

Diagnosis 596 

Prognosis 597 

Statistics  of  labial  cancer .  598 

Treatment 599 

CHAPTEE  XVIII. 

Tongue 607 

Surgical  anatomy 607 

Deformities 609 

Lingual  prolapsus,  with  hyper- 
trophy    610 

Treatment 611 

Ankyglossa,  or  tongue-tie    .    .  613 
Glossitis,  or  inflammation  of  the 

tongue 615 

Treatment 617 

Abscess  of  the  tongue    ....  618 

Ulceration  of  the  tongue  .    .    .  618 

Treatment 620 

Growths  of  the  tongue  ....  622 

Treatment 623 

Cystic  growths 624 

Fibroma  of  the  tongue  ....  626 
Malignant      growths     of     the 

tongue  .    .  " 626 

"Wounds  of  the  tongue  ....  643 
Foreign   bodies  lodged  in  the 

tongue 644 

Roof  of  the  oral  cavity  .    .    .    .  644 
Inflammation    of    the    palatal 

structures 647 

Treatment  .....  648 

Wounds  of  the  palate   ....  649 

Tumors  arising  from  the  palate  650 

Aneurism 650 

Malformations  of  the  soft  and 
hard  palate;  acquired  or  con- 
genital    652 

Treatment 653 


vm 


COXTKNTS. 


FAliE 

Palatal  adhesion ti56 

Destruction   of  the  uviihi  iiiul 
soft  palate 657 

CHAPTER  XIX. 

Palatal  Cleft  or  Division-   ,    .  659 

Treatment 663 

Stapliyl<irrai)hy 665 

Uranoplasty 677 

CHAPTER  XX. 

Tonsil 686 

Surgical  anatomy 686 

Tonsillitis 688 

Treatment  .    .     .....  694 

Hypertrophy  of  the  tonsil.  .    .  6117 

Treatment 700 

Tonsillotomy,   amygdalotomy, 

or  excision  of  the  tonsils.  .  .  701 

Tonsillar  tumors 710 

Treatment 711 

CHAPTER  XXI. 

Pharynx 713 

Abscess  of  the  pharynx.  .    .    .  713 

Treatment 716 

Ulceration  of  the  pharynx  .    .  719 

Treatment  .......  720 

Pharyngeal  tumors 721 

Foreign  bodies  in  the  pliarynx,  723 

CHAPTER  XXII. 

•  Sublingual  Region 725 

Ranula 727 

CHAPTER  XXIII. 

Maxilla  Inferior 732 

Surgical  anatomy 732 

Congenital   deformity  ....  733 
Alveolar  periostitis,  gingivitis, 

and  dental  abscess 7?>3 

Treatment 734 

Dental  fistula 734 

Treatment 7-36 

"Wisdom  teeth 736 

Necrosis  of  the  lower  jaw  .  .    .  738 

Prognosis 741 

Treatment 741 

Phosphorus-necrosis 743 

Treatment 746 

Growths  in  the  maxilla  inferior.  748 

Maxillo  dental  cystic  tumors.  .  748 

Treatment.  ". 752 

Odontoma 752 

Treatment 753 

Fibroma 754 

Epulis 755 

Treatment 757 

Malignant  growths 758 


PAGE 

Carcinoma 758 

Treatment TOO 

Ancliylosis  of  the  maxilla    in- 
ferior          .    .    764 

Treatment 765 

Luxation  of  the  maxilla  inferior  770 

Treatment 773 

Fracture    of    the    lower    jaw, 

Treatment 775 

CHAPTER  XXIV. 
Facial  Neuralgia 783 

CHAPTER  XXV. 

Neck 800 

Surgical    Anatomy 800 

Torticollis.  .    .    .  ' 804 

Treatment 808 

CHAPTER  XXVI. 

Congenital  Clefts  or  Fistul.e 

IN  THE  Neck 810 

Treatnaent 822 

Thyroid  Gland,  and  its  Affec- 
tions  823 

Surgical  anatomy 823 

Goitre  .... 625 

Treatment. 834 

Medical 835 

Surgical 838 

Exophthalmic  goitre 847 

jMalignantdisea.se  of  the  thvroid 

gland *       .849 

Wounds  of  the  thyroid  gland  .  850 

Thyroiditis 851 

Phlegmon  and  abscess  of  the 

neck 853 

Treatment 858 

Drainage 860' 

CHAPTER  XXVII. 

Tu.MORS  OF  THE  Neck 864 

Treatment 867 

Lymphangioma 867 

Angioma 869 

Treatment 870 

Blood-cysts 871 

Treatment 873 

Solid  growths  of  the  neck.  .    .    873 
Sarcoma  of  the  cervical  glands.  874 
^lalignant  lymphoma  ....    877 
Treatment  of  cervical  glandu- 
lar tumors 880 

Carbuncle,  anthrax 893 

Diagnosis 895 

Prognosis 896 

Treatment.  ...  .896 

Malignant  pustule 900 

Pathological  changes  pre- 
sent after  death  ....    902 
Treatment 902 


'       CONTEXTS.  *                                                      IX 

CHAPTER  XXA'III.  ,                                               page 

PAGE  Malignant     growths      in     the 

WocxDS  OF  THE  Xeck 905  pharj'ns  and.  cesophagus  .    .     992 

Treatment 915  Wounds  of  the  cesophagus  .    .     998 

Fracture  of  the  h  void  bone...    922  TPvAcnEOTOMY  or  Bkoxchotomy..1000 

Treatment   / 923 

Fracture  of  the  larynx.     ...    923  CHAPTEE  XXXII. 

Symptoms 924  t 

Treatment  9'>4      Lartxgotomt 1069 

Strangulation,  hanging.  .'    '    '    925  Operation  of  laryngotomv.  .    .  1075 

Hanging  .    .    .\        .    .    .    929  Intubation 1078 

Artificial  respiration .    .    .    935  „„    x-rr-r-x.   -w^ttt 

Insufflation. 935  CHAPTEE  XXXIII. 

Aspiration 938  Extiepatiox  of  the  Laktstx  or 

Drowning.    ...    .           .    946  Opekatioxof  Laetxgectomy,1086 

±  oreign  bodies  m   the  air  ' 

P^'^^S*^* ^-5^  CHAPTEE  XXXI Y. 

(2;2;^P'pj;p^  XXIX  Vessels  oe  the.  Xeck 1056 

Atfections  of  the  carotid  artery.1098 

CEsoPHAGrs 959  Ligation     of     the      primitive 

Congenital  defects  of  the  cesoph-  carotid 1101 

agus 961  Ligation     of     both     primitive 

Stricture  of  the  oesophagus.'    .    963  carotids 1120 

Spasm 971  Ligation  of  the  external  carotid 

Treatment   .......    974  artery 1120 

Subclavian  artery 1127 

PTT  A  -PTVT>   vv V  Ligation  of  the  external  jugu- 

CHAPIEK  XXX.  lar  ^ein 1131 

FOREIGX    Bodies    ix    the    Pharyxx  Wounds  of  the  internal  jugular 

AXD  (Esophagtis 982  ^          ™^  i  i   V  "  /./        ■    ^^^    \ 

Congenital  defects  of  the  spinal  col- 

.  umn  (spina  bifida) 1139 

CHAPTEE  XXXI.  Treatment 1141 

Pharyngeal   axd    (Esophageal  ^tt  » -Drr-17-D  -k-^^^ 

Neoplasms 989  CHAPiEK  XXXV. 

Treatment 990  Luxatiox  or  the  Certical  Yer- 

Warts,     cysts     and     polypoid  tebr^ 1144 

growths  in  the  cesophagus  .    991  Fracture  of  the  vertebrae,.    .    .  1150 


LIST  OF  ILLUSTRATIONS. 


.-fIG.  PAGE 

1.  Lobes  of  the  Brain Original 192 

2.  Osteoplastic  Method  of  Trephining —         206 

3.  Martino's  Method  of  Lessening  the  Pinna   .  —         289 

4.  Plastic  Method  of  Celsus  .    .  \ Otto  Weber 410 

-    -r.1  •        1     j^-     -r>         1                                             \  Dictionaire  Encyclopedique^  .,„ 

■a.  Khmoplastic  Procedure |  des  Sciences  Medicales      T^'^ 

6.  Alquie's  Khinoplastic  Method "  413 

7.  Talicotian  Method  of  Khinoplasty —          419 

8.  Plastic  Surgery— the  Circle —          429 

9.  The  Semicircle —          429 

10.  The  Ellipse —          429 

11.  The  Oval —          420 

12.-  The  Triangle  of  Equal  Sides —          . 429 

13.  "            "         with  Two  Equal  Sides  ....  —          429 

14.  The  Eectangle —          429 

15.  The  Parallelogram —          429 

16.  The  Khomboid —          429 

17.  Khomboid  Slightly  Lengthened —          430 

18.  Khomboid  Much  Elongated —          430 

19.  The  Lozenge —          430 

20.  The  Sector —          430 

21.  Closure  of  Circle —          430 

22.  "       "   Parallelogram —          431 

23.  "       '*    Equilateral  Triangle —          431 

24.  "       "    Khomboid  Space;  Ellipse  and  Oval  —          431 

25.  Triangle  with  Opening  in  Base —          432 

26.  "            "     Closure    "      «      —          432 

27.  Two  Parallelograms  Resting  on  Same  Base   .  —          434 

28.  "                 "             Closing  Defect   ....  —          434 

29.  One  Method  of  Closing  Triangular  Defect  .    .  —          435 

30.  Sutural  Line  Kemaining  after  Closure   ...  —          435 

31.  Burow's  Plan  of  Closure ...  —          435 

32.  Sutural  Lines  after  Closure  by  Burow's  Plan  —          436 

33.  "             "     of  Two  Triangles  .    .        ...  —          436 

34.  Two  Triangles  Exsected — 436 

35.  Closing    Triangular    Defect    by   Curvilinear 

Extension —          437 

36.  Plan  of  Closure  of  Lozenge-shaped  Defect  .  —          437 

37.  Sutural  Lines  after  Closure  of  Lozenge-shaped 

Defect —         ^ 487 

■38.  Plan  of  Closing  a  Parallelogram —  ....'...  438 

39.  Line  of  Suture  after  Closure  of  a  Quadrangu- 

lar Defect —          438 

40.  Plan  of  Closing  a  Quadrangular  Defect   .    .  —           438 

41.  Sutural  Lines  after  Closure  of  Quadrangular 

Defect —          438 

42.  Another  Plan  of  Closing  Quadrangular  Defect  —          439 

43.  Sutural  Line  Remaining  after  Closure  of  Space 

Indicated  in  Figure  42 —          439 

.44.  Closure  of  Rectangular  Defect —          439 

45.  Lateral  Closure  of  a  Kectano;le —          439 

46.  Method  of  Closing  a  Circular  Defect  ....  —          440 

(xij 


Xii  LIST    OF    ILLUSTKATIUNS. 


FIG. 


PAGE 


47.  Appearance  after  Closure  of  Circular  Defect  .  —          440 

48.  Closure  of  the  Circular  Defect —          -l-H 

49.  Sutural  Lines  after  Closure  of  Circle  ....  —          4^1 

50.  Method  of  Closing  Semicircular  Defect  ...  —          441 

51.  Closure  of  Triangle —           442 

52          "                   "         Second   Plan. —          442 

53.  "                   "         Third  Plan —          442 

54.  Plan  of  Closing  a  Quadrangle :  —          442 

55.  Closure  of  Oval  Space —          443 

56.  Sutural  Line  after  Closure  of  an  Oval  Defect  —          448 

57.  Plan  of  Closing  a  Semicircular  Space   ...  —          443 

58.  Sutural   Line   after  Closure   of  Semicircular 

Defect —         443 

59.  Another  Plan  of  Closing  a  Semicircular  De- 

fect   —          443 

60.  Closure  of  a  Semicircular  Space —          444 

61.  Dietlenbach's  Method  of  Operating  for  Eelief 

of  Palpebral  Eversion —          480 

62.  Von  Amnion's  Plan  of  Operating  in  Ectropion  —          480 

63.  Syzmanowsky's  Method  of  Operating  in  En- 

tropion     —          481 

64.  Sutural  Line  llemaining  after  Sj-zmanowsky's 

Operation —          481 

65.  Bonnet's  Plan  for  Eversion  of  Eyelid  .    ...  —          482 

66.  T.  Wharton  Jones'   Operation  for  Belief  of 

Ectropion —          483 

67.  Guerins   Method  for  Kelief  of  Eversion   of 

Lower  Eyelid —          483 

68.  Denonvilliers'  Plan  of  Elevating  Outer  Angle 

of  the  Eye —          484 

69.  Dieflfenbach's  Plan  for  Correcting  Ectropion  .  —          485 

70.  Plan  of  Anagnostakis  for  Kelief  of  Entropion  —          489 

71.  Sutural  Line  after  Operation  of  Anagnostakis  —          489 

72.  Epicanthus  of  the  Eye ".    .    .    .  —          490 

73.  Hasner's  Plan  of  Kemoving  Neoplastic  Disease  —          492 

74.  Burow's  Method  <>f  Kemoving  a  Portion  of 

Lower  Eyelid   ....        —          493 

75.  Plates,  Showing  Development  of  Fa?tal  Head  From  Von  Amnion  .    .    .  55*5 

76.  Graefe's  Plan  in  Treatment  of  Hare-lip  ...  —          567 

77.  "           "    Modified  by  Bruns From  Weber 567 

78.  Sedillot's  Plan  in  Hare-lip —          568 

79.  Result  in  S^dillofs  Plan —          568 

80.  Metliod  Employed  by   Mirault,    Henri,  and 

Malgaigne —          -309 

81.  Result    of    Method    Employed    by   Mirault, 

Henri,  and  Malgaigne —          509 

82.  Mirault's  Method —          569 

83.  Result  of  Mirault's  Method —          569 

84.  SMillot's  Plan  for  Closure  of  Breach  in  Lower 

Lip —          602 

85.  Result  of  Closure  by  SediUot's  Method  .    .    .  From  Emmert   ....  002 

86.  Interdental  Gag OrUjinal (541 

87.  Davies-Colley's  Uranoplastic  Procedure  .    .    .  —          683 

88.  Appearance  after  Closure  According  to  Plan 

of  Davies-Colley T  .    .    .    .  —          684 

89.  Enormous  Maxillary  Fibroma Baucltot 754 

90.  Luxation  of  Inferior  Maxilla —          772 

91.  Apparatus  of  Bonnet  for  Correcting  Torticollis  —          815 

92.  Transfixor  Used  in  Enucleation  of  Goitre  .    .  Original 843 

93.  A  Sarcomatous  Tumor "          «75 

^.    T,  T>   1  1  *  J  rr  ( Dlctlonalre  Fncyclopec/ir/ue}  ooi 

94.  Enormous  Pedunculated  Tumor |  des  Sciences  mdLalei     }  ^^^ 

95.  Marshall  Hall's  Method  of  Artificial  Respira- 

tion    From  Holmes^  Surgery  .  939 


LIST    OF    ILLUSTRATIONS. 


XllI 


FIG. 

96.  Howard's  Method  of  Artificial  Kespiration 

97.  Silvester's  Method  of  Artificial  Eespiration 

98.  Instrument  Used  in  Opening  (Esophagus  . 

99.  Mathieu's  (Esophageal  Forceps 

100.  Canula  . 

101.  Blunt  Retractor — 

102.  "      Dissector — 

103.  Canula  of  Usual   Form — 

104.  "        with  Inner  Tube  "Withdrawn  .    ...  — 

105.  O'Dwyer's  Instruments  for  Intubation  ...  — 

106.  Gussenbauer's  Artificial   Larynx From  Schuller 1094 

107.  Complete  Antero-posterior  Luxation  of  Spine     From   Albey^t 1145 

108.  Bilateral  Luxation  of  Spine .  ''  1145 

109.  Complete  Fracture  of  Vertebral  Column  .    .  "  1152 

110.  Fracture  of  a  Vertebra "              .   .       '    .  1152 


PAGE 

From  Holmes'  Surgery       940 

"  .941 

Vaca  Berlinghiera  .    .    .    978 

—  986 

From  Schuller 1006 

—  • 1041 

—  1041 

—  1043 

—  1043 

—  1081 


INTRODUCTION. 

Bacteriology,  Antisepsis,  Asepsis. 

The  following  work  was  commenced  soon  after  the  birtn  of 
Bacteriology,  and  the  subject  matter  of  that  science,  thougii 
tacitly  accepted,  demands  further  mention  than  has  been  given 
to  it  in  the  following  pages.  To  meet  this  want,  a  brief  consider- 
ation of  this  new-born  science  will  herewith  follow. 

One  of  the  first  to  teach  that  many  diseases  are  caused  by  a 
fungoid  agent  was  Dr.  J.  K.  Mitchell  of  Philadelphia.  Dr. 
Mitchell,  in  a  course  of  lectures  heard  by  the  author  in  1850, 
with  great  fervor  taught  the  doctrine  that  cholera,  yellow  fever, 
and  other  contagious  or  infectious  diseases,  originate  from  a 
portable  microscopic  entity.  Many  proofs  of  this  doctrine  were 
presented  by  Mitchell,  and  the  belief  expressed  that  it  would  be 
fully  verified  in  the  future.  In  1858  Pasteur  announced  his 
doctrine  that  fermentation  and  putrefaction  are  produced  by 
microscopic  agents  of  which  tlie  germinal  elements  are  in  the 
surrounding  air.  One  of  the  pioneer  lectures  on  these  subjects 
delivered  in  the  French  Institute  was  listened  to  by  the  writer. 
The  words  uttered  then  by  Pasteur  were  pregnant  with  more 
import  than  he  or  his  audience  wei'e  aware  of:  they  were  the 
magical  utterances  which  heralded  the  birth  of  a  new  science — 
Bacteriology.  In  this  early  work  one  of  the  chief  objects  aimed 
at  by  the  French  savant  was  to  disprove  the  doctrine  of  spon- 
taneous generation,  and  to  prove  that  every  living  entity,  whether 
a  microbe  or  a  macrobe,  owes  its  origin  to  a  preexistent  one. 

In  his  studies  of  fermentation  and  putrefaction  Pasteur  deter- 
mined that  fermentation  has  its  specific  ferment,  consisting  of 
living  cells;  he  also  discovered  that  putrefaction  is  induced  by 
an  organized  minute  agent;  and  that  the  causal  agents  of  fer- 
mentation and  putrefaction  are  universally  present  in  the  air,  or 
contiguous  bodies. 

These  microscopic  entities  were  named  by  Sedillot  microbes, 
and  this  name  was  satisfactory  to  those  who  claimed  that  they 
were  animalcules,  and  who  named  them  microzoa;  and  the  name 
microbe  was  acceptable  also  to  the  opposite  party,  who  classed 
these  entities  with  plants,  and  named  them  microphytes. 

Through  the  studies  of  Cohn,  de  Barry,  Nsegeli,  and  others 

(XV) 


Xvi  IXTRODUrTIOX. 

it  has  been  established  that  these  microscopic  agents  belong  to 
the  lowest  orders  of  plants. 

Tiie  new  field  of  !-cieiUific  research  oi)ened  by  Pasteur  was 
quickly  entered  by  Davaiue,  Koch,  Sternberg,  and  many  others ; 
and  from  the  united  labors  of  these  investigators  have  sprung 
the  germ  theory  of  the  origin  of  many  diseases,  the  knowledge 
that  many  diseases  may  be  successfully  combated  by  inoculation, 
and  from  the  discoveries  of  these  men  conjoined  with  those  of 
Lister,  Aseptic  Surgery  has  been  born  and  developed. 

This  work  took  a  practical  turn  in  18G0,  when  Pasteur 
discovered  the  micro-organism  which  destroys  the  silkworm. 
Anthrax  or  splenic  fever  which  is  so  fatal  to  cattle,  and  the 
cholera  of  swine  and  chickens,  were  soon  found  to  de})end  upon 
a  portable  parasite.  And  those  morbific  entities  being  discovered, 
the  .scientist  next  suggested  remedies  against  them. 

The  morbific  agents  of  disease  in.man  are  chiefly  microjdiytic 
in  nature;  a  few  are  animalcular  or  protozoic.  In  the  class  of 
microphytes  are  included  Bacteria,  wliich  arc  so  named  because 
many  of  them  are  rod-shaped. 

Cohn  divided  bacteria  into  four  classes,  viz.,  those  of  globular 
form,  of  tlie  form  of  short  rod.s,  of  the  form  of  longer  rods,  and 
tlio.se  of  spiral  shape.  The  first  class  is  now  named  Cocci,  the 
second  ;ind  third.  Bacilli,  and  the  fourth  class.  Spirilla.  Another 
classilic-ation  of  bacteria,  founded  on  their  method  of  reproduc- 
tion, is  into  two  groups,  viz.,  those  reproduced  from  endospores, 
and  those  from  arthrospores.  The  triple  cla.ssification,  founded 
on  the  form  of  the  Bacteria,  is  the  one  usually  adopted,  and  a 
diagram  showing  these  forms  is  here  presented. 


FiGL'UK  1.     a  cocci;  6  bacilli;  c  spirilla. 


The  surgeon  in  his  work  is  only  concerned  with  the  coccus 
or  round,  and  the  bacillus  or  rod-shaped  bacteria. 

Cocci  appear  in  isolation,  in  regular  groups,  or  in  irregular 
masses.  When  they  exist  singly  and  separate,  the  cocci  are 
named  monococci;  when  in  pairs,  they  are  named  di[)lococci,  and 
when  four  are  grouped  together,  they  are  denominated  tetracocci; 
and  when  they  are  linked  together,  chain-like,  they  are  named 
strei>tococci.  When  the  cocci  are  aggregated  in  irregular  masses, 
they  are  designated  by  the  term  zoogloea;  and  when  in  clusters, 
they  are  named  staphylococci.  A  mass  of  cocci  inclosed  in  a 
capsule  is  named  ascococci. 


BACTERIOLOGY,    ANTISEPSIS,    ASEPSIS.  xvii 

Bacterial  organisms  are  cells  which  have  an  average  diam- 
eter of  one-thousandth  of  a  millimeter.  The  cell  consists  of  a 
wall  within  which  is  a  homogeneous  or  granular  protoplasmic 
material.  The  cell  is  ordinarily  colorless.  From  contact  with 
water  the  cell  wall  may  hecome  gelatinoid;  and  in  this  condition 
the  cells  may  cohere  in  chain  form,  or  aggregate  in  the  irregular 
masses  named  zoogloca. 

The  ]nost  of  bacteria  are  capable  of  locomotion,  in  which 
they  are  seen  to  rapidly  move  in  the  containing  fluid  from  place 
to  place,  in  a  very  irregular  manner.  Other  bacteria,  instead  of 
progression  exhibit  vibratory  movements,  dependent  on  molecular 
movement  of  the  cellular  content.  Rod-shaped  bacilli  are  some- 
times provided  with  cilia-like  appendages,  which  are  attached  to 
the  ends  or  sides,  and  these  appendages,  like  fins,  may  aid  in 
propulsion.  They  may  also  aid  the  microphyte  in  getting  its 
nutriment. 

Bacteria  placed  in  proper  conditions  have  the  endowment  of 
rapid  multiplication;  and  reproduction  may  occur  by  segmenta- 
tion or  sporulation.  Reproduction  of  the  coccus  by  segmentation, 
in  four  different  stages,  is  shown  in  Figure  2.     And  segmentation 


Figure  2.     Divibion  ot  coccus.     (After  Mace.) 
of  a  bacillus,  in  its  five  successive  stages,  is  shown  in  Figure  3. 


Figure  3.     Division  of  a  bacillus.     (After  Mace.) 

Instead  of  development  by  simple  division,  bacterial  repro- 
duction may  occur  by  means  of  spores,  which  correspond  to  the 
seeds  of  ferns.  Most  bacilli  grow  by  njeans  of  spores.  There 
are  two  ways  in  which  the  growth  by  spores  may  occur :  in  one, 
the  embryo  appears  within  the  mother-cell;  and  this  mode  of 
reproduction  is  named  endosporous;  and  in  a  second  wa}^  the 
offspring  appears  as  an  appendage  to  the  mother;  and  this  mode 
is  named  arthrosporous.  These  modes  of  development,  which 
are  also  respectively  named  endogenous  and  exogenous,  are 
shown  in  Figure  4  on  page  xviii. 

If  sporulation  be  intra-cellular,  the  spore  may  appear  at  any 
point  within  its  progenitor.  It  begins  as  one  or  several  granules 
within  the  parental  protoplasm  ;  and  this,  enlarging  and  acquir- 


XVIU 


INTKODUCTION. 


^03Cii^# 


i'lciUKE  4.     buowiiig  growth 
within  and  outside  of  the  parent 
(After  de  Barry.) 


cell 


iiig  a  capsule,  liually  encroaches  on  the  wall  of  the  parent,  when 
the  latter  is  opened,  and  the  spore  escapes. 

The  mode  of  development  by  arthrosporous  (budding)  growth 
lias  not  been  very  definitely  made  out:  in  iacl,  some  bacleriol- 
ogists  deny  that  it  occurs. 

Bacteria  have  tiie  endowment  of  great  reproductive  activity. 
It  has  boon  calculated  that  a  single  cholera   bacillus,  of  which 

the  reproduction  is  by  segmenta- 
tion, can  produce  sixteen  million 
descendants  in  one  hour.  A  fluid 
or  senii-fluid  medium,  which  con- 
tains tiie  proper  nutrient  elements 
for  bacteria,  together  with  warmth, 
constitutes  the  ground  and  envi- 
ronment necessary  for  the  rapid 
develoj)ment  of  bacteria. 

The  bacterial  spore  possesses 
great  inherent  vitality;  it  will  live 
in  conditions  which  are  destructive 
to  all  other  forms  of  life.  Many  are 
only  <lestroyed  after  an  exposure  of 
several  hours  in  dry  jiir  heated  to 
140  degrees  centigrade.  Fully-develo[)ed  bacteria  {ire  destroyed 
at  a  much  lower  gi-ade  of  heat  than  that  re(|uired  for  destruction 
of  their  spores,  bi  a  course  upon  Biology  given  by  Professor 
Huxley,  attended  by  the  writer,  the  former  showed  that  if  milk 
or  water  and  cheese  containing  bacteiia  be  heated  to  (iO  degrees 
centigrade,  the  parasites  were  destroyed;  but  if  the  heat  be  some- 
what increased,  the  bacteria  reappeared;  when,  however,  the  heat 
was  raised  to  110  degrees,  there  was  no  reappearance  of  the 
parasites.  The  writer  thinks  it  probable  that  the  more  advanced 
microscopy  of  to-dny  would  fail  to  verify  those  phenomena  ob- 
served a  quarter  of  a  century  ago. 

Botli  bacteria  and  their  spores  successfully  resist  chemical 
and  physical  agents  which  are  fatal  to  all  other  forms  of  animal 
and  plant  life. 

There  are  many  varieties  of  bacteria;  and  each  one  maintains 
its  form  and  properties  through  countless  generations.  They  are 
incapable  of  miscigenation  and  the  development  of  hybrid  forms. 
Most  bacteria  thrive  best  when  they  can  obtain  a  free  supply  of 
oxygen  from  the  air;  and  these  are  named  aerobic.  Others  only 
grow  when  air  is  absent,  and  they  are  destroyed  by  free  oxygon; 
and  these  are  designated  as  anaerobic.  Tlie  bacillus  of  tetanus  is 
anaerobic.  A  third  class  tlnive  in  aii-,  and  also  where  air  is 
absent;  and  these  are  named  facultative  bacteria.     The  micro- 


BACTERIOLOGY,    ANTISEPIS,    ASEPSIS.  xix 

organisms,  the  causes  of  disease  in  man,  belong  to  the  class  of 
facultative  bacteria.  Some  bacteria  only  live  in  the  dead  bodies 
of  organized  beings;  and  these  are  named  sap ropliytes;  and  they 
live  at  a  low  temperature, 

A  high  or  low  temperature  arrests  the  growth  of  certain 
microbes;  and  growtli  is  resumed  at  an  intermediate  degree  of 
iieat.  Some  require  nearl}'  a  constant  heat,  as  the  bacillus  of 
tuberculosis.  Other  species  can  withstand  liigh  heat  and  extreme 
cold;  and  these  may  be  frozen  and  then  restored  to  life  by 
warmth.  Hence  cold  merely  retards  bacterial  life;  but  it  may 
be  extinguished  by  a  high  grade  of  lieat.  Moist  heat  is  more 
destructive  tlian  dry  heat.  Boiling  water  will  destroy  all  micro- 
organisms which  do  not  develop  by  spores.  Electricity  retards 
the  growth  of  bacteria;  and  sunlight  is  destructive  to  them, 
especially  to  the  bacilli  of  tuberculosis. 

For  development,  bacteria  require  a  soil  from  which  they  can 
obtain  suitable  nutrient  material,  and  also  an  environment  of 
warmth  and  moisture.  Some  demand  an  albuminous  nutriment, 
others  a  compound  of  carbohydrates;  and  all  require  hydrogen, 
oxygen,  nitrogen,  carbon,  lime,  and  potassium. 

The  tissues  of  man  and  animals  often  become  the  nutrient 
soil  for  bacteria.  The  man  in  perfect  health,  whose  tissues  are 
in  perfect  integrity,  is  usually  proof  against  bacterial  attack;  but. 
if  his  vital  power  be  diminished  by  traumatism  or  other  morbific 
agency,  then  he  becomes  a  prey  to  micro-organisms,  which  exist 
in  his  cuticular  or  mucous  teguments,  or  in  earth,  air,  water, 
or  in  organisms,  living  or  dead,  around  him.  And  persons 
in  apparent  health  differ  in  respect  to  susceptibility  to  bacterial 
disease. 

Many  bacteria  are  causal  agents  of  fermentation,  and  if 
fermentation  is  attended  by  the  production  of  ill-smelling  gases, 
the  process  is  named  putrefaction. 

Bacteria  have  physical  properties,  among  which  the  following 
may  be  mentioned:  A  few  have  the  power  to  form  pigmentary 
matter,  either  in  themselves  or  in  material  which  they  set  free. 
The  blue  color,  sometimes  seen  in  pus,  arises  from  a  bacterial 
pigment.  Some  bacteria  give  a  phosphorescent  appearance  to 
the  structure  which  contains  them.  Some  yield  an  odor  which 
may  be  agreeable  or  disagreeable.  Bacteria,  like  man,  take  in 
oxygen  and  nutrient  material,  which  they  assimilate,  and  their 
brief  life  is  crowded  with  activity,  in  which  are  produced 
ptomaines,  toxins,  toxalbumens,  and  antitoxins. 

A  ptomaine  is  an  inanimate  septic  substance,  which  arises 
in  dead  animal  or  vegetable  matter.  It  is  a  metamorphic  ma- 
terial  in   a  state  of  mutation;    and   from   being   found  in  the 


XX  INTRODUCTION. 

putrefying  animal  body,  and  yielding  an  alkaloid  reaction,  it  is 
named  a  cadaveric  alkaloid.  Some  ]>tomaines  are  ])oisonous, 
others  are  harmless.  Some  are  the  analogues  of  vegetal^Ie  alka- 
loids, viz.,  of  atropine,  nicotine,  morphine,  strychnine,  etc.  Many 
ptomaines,  when  introduced  into  the  animal  body,  have  the 
same  effect  as  do  their  bacterial  progenitors. 

A  second  agent  which  originates  directly  or  indirectly  from 
bacteria,  is  the  toxin.  This  is  thought  to  be  set  free  from  the 
bodies  of  degenerating  microbes;  or  in  the  changes  which  bac- 
teria induce  in  the  tissues,  toxins  may  be  generated.  Some  of 
these,  as  the  tetanus-toxin,  are  intensely  poisonous,  and  are 
rapidly  absorbed.  Bacteria  generate  and  excrete  another  sub- 
stance, akin  to  a  ferment,  which,  acting  on  the  cells  of  the  con- 
taining tissue,  produces  a  substance  named  toxalbumen,  which 
may  act  on  the  body  as  a  poison.  This  may  be  produced  in  the 
laboratory;  it  gives  the  reactions  of  albumen,  and  is  not  alkaline. 

Another  important  product  of  bacteria  is  that  which  is  named 
antitoxin.  The  origin  of  antitoxins  has  not  been  settled  beyond 
question;  possibly  instead  of  arising  from  bacteria,  antitoxins 
may  originate  in  the  cells  of  the  body  in  which  the  bacteria 
are  lodged.  Should  the  origin  be  in  the  parasite,  then  bacteria 
have  the  double  endowment  of  producing  poisons  and  their 
counter-poisons. 

The  toxins  and  antitoxins  are  procured  in  isolation  by  the 
filtration  of  bacterial  cultures:  Thus,  to  obtain  the  toxins,  a 
culture  containing  them  is  placed  in  a  cylinder  of  porcelain, 
kaolin  or  asbestos,  when  the  toxin  containing  serum  will  j)a.ss 
through  the  wall,  while  the  bacteria  will  remain  in  the  scrum. 
The  .serum  which  has  transuded  is  next  treated  with  chemical 
agents,  and  the  toxin  is  thus  obtained.  The  antitoxins  are 
procured  by  filtering  through  a  specially-constructed  filter  the 
serum  of  animals  which  liave  been  rendered  immune. 

By  immunity  is  meant  that  the  body  of  man  or  an  animal  is 
insusceptible  to  disease;  and  the  immunity  may  exi.st  in  reference 
to  more  than  one  disease.  An  exemplification  of  immunity,  long 
known,  is  that  furnished  by  vaccine  virus  against  variola.  The 
bacteriologist  has  furnished  an  immunizing  agent  against  diph- 
theria, hydrophobia,  tetanus,  glanders,  anthrax,  and  })neumonia; 
and  such  agent  may  act  in  a  two-fold  manner,  viz.,  preventively, 
it  may  render  the  subject  immune,  or  proof  against  the  disease. 
or  if  he  l)e  already  affected  with  the  disease,  the  latter  may  be 
rendered  milder  by  the  immunizing  agent.  And  such  treatinent 
is  named  orrhotherapy.  or  serum-therapy.  The  enthu.siastic 
claims  made  for  serum -therapy,  for  establishment.  re(iuire  to  be 


BACTERIOLOGY,    ANTISEPSIS,    ASEPSIS.  XXI 

tested  by  time,  severe  examination,  skepticism  and  cool  obser- 
vation. 

Immunity  may  naturally  exist  in  man  against  disease  com- 
mon to  animals;  and  the  converse  is  true  of  animals  in  respect 
to  human  disease.  Artificial  immunity  may  be  acquired  by 
man  and  animals,  in  several  ways;  it  may  be  produced  by  inocu- 
lation with  an  attenuated  virus,  of  which  a  familiar  example  is 
vaccine  virus.  Immunizing  inoculation  is  done  with  a  sterilized 
culture  in  which  the  toxic  bacteria  have  been  destroyed.  And 
similar  work  has  been  done  by  the  intravenous  injection  of 
highly  attenuated  virulent  cultures. 

The  serum  of  normal  blood  is  antagonistic  to  bacteria;  and 
when  the  latter  are  injected  into  the  vessels  of  a  living  animal, 
the  germs  soon  disappear;  or  rather,  they  become  stranded  in 
certain  viscera,  as  the  liver  and  spleen,  where  they  die,  disin- 
tegrate, and  vanish. 

The  power  to  destroy  bacteria  is,  according  to  certain  author- 
ities, possessed  by  white  blood-cells,  connective-tissue  cells,  mucous 
cells,  endothetial  cells,  and  glandular  cells.  This  doctrine 
was  announced  by  MetschnikofF,  and  has  been  accepted  by  a 
number  of  pathologists,  and  strongly  op])Osed  by  others. 
MetschnikofF  taught  that  when  bacteria  are  admitted  into  the 
living  body,  there  soon  ensues  a  struggle  between  them  and 
the  bodily  cells  before  mentioned;  and  that  the  victory  is  to  the 
stronger  party.  The  leading  defendants  of  the  body  are  the 
leucocytes,  which  receive  into  their  interior  the  microbic  entities 
and  destroy  them,  the  process  being  similar  to  that  which  occurs 
when  a  larger  animal  swallows  and  ends  the  life  of  a  smaller  one. 
If,  on  the  contrary,  the  bacteria  be  superior  in  force  and  energy, 
the  victory  is  theirs.  This  hostile  action  between  living  cells 
and  bacteria  is  named  phagocytosis;  and  the  devouring  cells  are 
named  pliagocyie.s.  From  the  writer's  study  of  this  matter  he 
infers  that  the  living  cells  have  had  their  day  of  phagocytic 
victories,  and  that  this  honor  will  hereafter  belong  rather  to 
the  serum  than  to  the  cells  of  the  blood. 

Since  the  announcement  by  Davaine  and  Koch  of  the  discov- 
eries which  they  liave  made  in  the  field  of  bacteria,  a  multitude 
of  investigators  have  entered  it  and  brought  to  light  a  great 
number  of  microbic  agents.  A  part  of  these  do  not  interest  us, 
since  they  have  no  morbific  action  on  man  and  animals;  another 
portion,  however,  do  concern  both  the  physician  and  the  surgeon, 
since  they  have  been  demonstrated  to  be  the  causal  agents  of 
disease  in  man.  Morbific  bacteria  are  named  pathogenic  organ- 
isms. An  enumeration  and  brief  notice  of  the  leading  patho- 
genic bacteria  will  herewith  follow: — 


xxii  introdt'ctiox. 

Bacili.is  Tuberculosis. 

The  bacillus  of  tuberculosis  was  discovered,  cultivated,  and 
demonstrated  by  Koch  to  be  an  inseparable  accompaniment  of 
tubercular  disease;  and  he  proclaimed  it  in  1882  to  be  the  causal 
agent  of  tuberculosis.  It  does  not  j)Ossess  the  ])Ower  of  motion, 
it  is  one  of  the  smallest  of  tlie  microbic  organisms,  its  volume 
being  equal  to  one-fourth  of  that  of  a  rod  blood-cell.  It  is  rod- 
shaped,  or  bacillary  in  form;  and  sometimes  it  is  curved  in 
form.  They  are  occasionally  found  in  groups  of  two,  so  disposed 
as  to  form  an  acute  angle.  It  thrives  well  on  blood-serum,  at  a 
temperature  of  100  degrees,  Fahrenheit.  It  can  be  grown  in 
other  media.  It  has  been  obtained  through  culture  in  branched 
and  club-shaped  forms.  Bovine  tubercle-bacilli  are  much  smaller 
than  the  tubercle-bacilli  originating  in  man. 

Tubercular  disease  in  animals  and  man  arises  from  this 
bacterium.  Tubercle-bacilli  are  the  causal  agents  in  man  of 
pulmonary  tuberculosis,  and  of  tubercular  disease,  whether 
seated  in  the  osseous  or  soft  structures  of  the  body.  Disease 
formerly  designated  scrofula  owes  its  origin  to  this  agent.  The 
tubercle-bacillus  is  found  in  tissues  the  seat  of  lupus. 

Koch  has  ])repared  a  lymph  from  tubercular  matter,  which 
is  known  under  the  name  of  tuberculin.  This  lymph,  for  a  time, 
was  believed  to  be  a  cure  for  tuberculosis;  this  hope  has  not  been 
realized,  yet  the  experience  had  with  tuberculin  has  led  to  the 
discovery  of  a  derivative  from  it,  known  as  oxtuberculin,  which 
experience  has  shown  to  be  a  valuable  remedy  against  some  forms 
of  tuberculosis. 

The  animal  body  is  infected  with  tubercular  disease  through 
the  breathing  of  air,  or  use  of  food,  containing  the  bacilli  of 
tuberculosis. 

Bacillus  of  Anthrax. 

Prior  to  the  era  of  bacteriology,  the  causal  agent  of  splenic 
fever  or  malignant  pustule,  now  usually  named  anthrax,  was 
investigated  by  Davaine,  in  France.  In  later  years,  the  knowl- 
edge of  anthrax  has  been  greatly  advanced  by  the  researches  of 
Pasteur  and  Koch.  The  anthracic  bacteria  are  shaped  like  rods, 
which  liave  broadened  ends,  and  in  their  dimensions  they  equal 
red  blood  corpuscles.  They  thrive  readily  in  different  culture- 
media,  and  ])roduce  spores  which  have  great  vitality.  In 
animals  which  have  died  from  anthrax,  the  blood  and  abdominal 
viscera  are  found  infected  with  bacilli.  If  tlie  elements  of  the 
di.sease  are  inhaled  they  cause  pneumonia.  It  occurs  as  a  local 
disease  in  men  whose  occupation  briuirs  them  in  contact  with 
animals  which  have  died  from  anthracic  disease.     The  disease 


PYOGENIC    BACTERIA.  XXIll 

commences  as  a  local  gangrene  of  the  infected  surface,  and 
spreading  rapidly  and  without  limitation  it  soon  destroys  life. 
Sometimes  the  writer  lias  stayed  the  disease  and  rescued  the 
patient  by  thermal  cauterization  and  the  local  use  of  bromine. 
This  treatment,  to  be  of  avail,  must  be  resorted  to  early. 
Animals  have  been  rendered  immune  through  inoculation  with 
an  attenuated  culture  of  the  antliracic  bacilli.  Through  his 
immunizing  work,  Pasteur  has  enabled  tlie  herdsman  to  save 
his  flocks,  which  formerly  perished  with  anthrax. 

Streptococcus  Erysipelatis. 

This  bacterium,  discovered  b}^  Fehleisen,  presents  itself  in  the 
form  of  a  coccus,  or  of  articulated  cocci.  It  was  discovered  in 
the  lymphatics  of  tissue  affectcl  with  erysipelas.  This  is 
believed  to  be  the  causal  agent  of  puerperal  fever.  It  has  been 
found  in  scarlatina,  variola,  and  cerebro-spinal  meningitis. 
This  microbe  formerly  abounded  in  tlie  foul  air  of  septic  hospi- 
tals, and  it  was  the  cnuseof  the  constant  prevalence  of  erysipelas; 
but  under  the  improved  sanitary  conditions  of  the  present  day, 
this  disease  seldom  occurs.  It  may,  however,  be  readily  gener- 
ated if,  in  a  suppurating  wound,  the  generated  pus  is  prevented 
from  escaping.  And  the  exanthema  having  commenced,  it 
spreads  cutaneously  and  subcutaneously ;  and  its  march  is  not 
alone  centrally,  corresponding  to  the  lymph  current,  but  it 
extends  quite  as  rapidly  peripherally. 

Pyogenic  Bacteria. 

Several  bacterial  fornis  precede  and  accompany  suppuration 
as  causal  agents.  About  the  time  that  Fehleisen  discovered  the 
coccus  which  is  the  cause  of  erysipelas,  Kosenbach  discovered  a 
bacterium  of  identical  form,  which  he  named  streptococcus 
pyogenes,  and  which  is  generally  found  in  suppurating  struc- 
tures. In  fact,  the  streptococcus  of  Fehleisen  is  believed  to  be 
the  same  as  that  discovered  by  Rosenbach.  Another  microphyie 
discovered  by  Rosenbach,  and  named  by  him  staphylococcus 
pyogenes  aureus,  is  more  generally  accepted  as  the  immediate 
cause  of  suppuration.  This  bacterium  is  nearly  always  found  in 
pus;  it  is  found  also  in  soil  and  water.  The  staphylococcus 
occurs  in  clustered  groups,  which  are  never  united  in  chain-form. 
They  are  motionless,  develop  in  moderate  temperature,  and  are 
anaerobic,  that  is,  they  can  exist  and  grow  without  air.  If  a 
culture  of  it  be  injected  into  a  serous  cavity  of  a  rabbit,  life  is 
quickly  destroyed  ;  but  if  the  material  be  injected  subcutaneously, 
the  action  is  limited  to  the  formation  of  an  abscess.  Instead  of 
presenting  a  yellow  hue  this  staphylococcus,  or  those  cognate  to 
it,  may  be  white  or  of  lemon  color. 


xxiv  INTRODUCTION. 

Through  the  action  of  chemical  or  pliysical  agency  on  living 
tissue,  its  life  may  be  tlestroyed  and  a  material  produced  which 
has  the  appearance  of  i)us.  But  such  pus  has  not  the  property 
of  propagation;  and  it  may  be  named  sterile  or  barren,  since  it 
is  not  inoculable,  and  cultures  can  not  be  grown  from  it;  in  fine, 
it  lacks  tlie  pus-germ.  Pus  capable  of  reproduction,  transi)lanta- 
tion,  and  dissemination  originates  from  a  bacterial  organism  of 
coccus,  streptococcus  or  staphylococcus  form.  Wiien  the  causal 
agent  is  in  staphylococcus  form  tlie  suppurative  action  is  local- 
ized, but  if  the  action  is  migratory,  it  is  due  to  streptococci. 

The  action  of  pyogenic  bacteria  consists  in  the  destruction  of 
the  component  cells  of  living  ti-^sne;  and  this  destructive  action 
takes  place  most  rapidly  in  tissue  known  as  inflammatory 
neoplasm,  granulative  or  embryonic  tissue,  and  also  in  tissue  of 
which  the  vitaHty  has  been  impaired  by  traumatism  or  other 
depressing  agency.  The  excreta  from  these  microbes  perform 
the  part  of  ferments  or  solvents,  and  thus  they  })revent  coagula- 
tion which  often  furnishes  a  barrier  against  purulent  infection. 
The  surgeon,  in  asepticising  the  surface  on  which  he  operates, 
and  who  afterwards  j)rotects  the  part  with  aseptic  dressing, 
guards  against  suppuration.  The  dermal  tegument  of  the  body 
when  in  com[)lete  integrity,  and  the  intact  mucous  membranes 
are  effectual  barriers  against  the  entrance  of  pyogenic  bacteria. 

Bacillus  Pyocyaneus. 

.  Pus  sometimes  has  a  blue  color,  arising  from  the  presence  of 
a  bacterium  known  by  the  name  of  bacillus  pyocyaneus.  This 
bacillus  is  rod-shaped  with  rounded  ends.  It  develops  in  the  air 
at  ordinary  temperature.  This  bacillus  thrives  rapidly,  and  it 
soon  imparts  a  blue  color  to  the  dressing  of  a  suppurating 
wound  which  contains  the  coloring  microbe.  Chlorinated  water 
is  destructive  to  it,  and  is  one  of  the  best  disinfectants  for  its 
extermination.  If  the  pyocyanic  pus  be  mixed  with  chloroform, 
the  pigment  is  precipitated  in  crystalline  form.  Blue  or  colored 
pus  is  not  more  infective  than  ordinary  i)us. 

Malignant  (Edema. 

A  number  of  years  ago,  Pirogofif  described  a  suppurative 
l)rocess  wdiich  he  named  purulent  or  malignant  (edema.  Its 
leading  characteristic  is  rapid  diffusion  and  destruction  of  the 
invaded  structures,  especially  of  the  subcutaneous  tissues.  The 
causal  agent  of  this  disease  was  discf>vered  by  Pasteur,  and 
named  by  ])im  septic  vibrio.  This  microphyte  was  found  later 
by  Koch,  and  described  by  him  as  a  bacillus  of  rod-shape.  It 
is  motile  and  grows  rapidly,  when  excluded  from  the  air.     It  has 


BACILLUS   OF    DIPHTHERIA.  XXV 

been  found  in  soil.  Parts  the  site  of  malignant  oedema  are 
tensely  swollen,  and  the  overlying  skin  has  a  glistening  appear- 
ance. Incisions  should  be  made  which  permit  the  escape  of 
albuminoid  serum,  and  lessen  tension.  And  the  affected  part 
should  be  dressed  with  carbolized  gauze. 

Bacillus  of  Tetanus. 

The  causal  microphyte  of  tetanus  has  been  especially  investi- 
gated by  the  Japanese  bacteriologist  Kitasato,  who  has  isolated 
and  made  a  culture  of  tlie  bacillus  of  tetanus.  In  form  it  is  a 
slender  rod,  in  the  tenninal  end  of  which  a  spore  is  developed, 
through  which  tliis  microbe  is*  propagated.  It  develops  very 
slowl}',  and  only  when  all  oxygen  is  excluded.  It  can  grow  in 
hydrogen.  It  has  slight  power  of  motion,  and  grows  in  a  tem- 
perature corresponding  to  that  of  the  human  body.  A  culture 
has  been  prepared  from  this  bacterium,  which,  injected  into 
animals,  produced  true  tetanus,  in  which  the  tetanic  spasms 
started  from  the  point  which  was  inoculated.  An  antitoxin,  or 
rather  an  antitetanic  remed}^  has  been  prepared  by  Tizzoni  from 
the  serum  of  animals  which  had  been  rendered  immune  by 
inoculation  with  a  sterilized  culture  of  the  tetanic  microphyte. 
This  has  been  used  in  tlie  treatment  of  patients  affected  with 
lockjaw,  and  some  seem  thus  to  have  been  cured.  Further  trial, 
however,  is  necessary  to  establish  the  efficiency  of  this  plan  of 
treatment. 

Bacillus  of  Diphtheria. 

This  bacillus,  discovered  by  Klebs  and  Loffier,  is  in  the  form 
of  a  slightly  curved  rod,  of  which  the  ends  are  swollen.  This 
bacterium  is  variable  in  shape,  and  in  normal  form  it  is  only 
found  in  diphtheritic  membrane.  It  has  no  movement;  and  its 
growth  is  favored  by  a  current  of  air.  A  culture  of  this  bacillus 
develops  diphtheria  at  the  site  of  inoculation,  and  it  can  produce 
general  paralysis.  A  toxin  is  developed  from  the  diphtheritic 
bacillus  which  was  isolated  by  Roux,  which  is  extremely 
poisonous,  and  speedily  destroys  the  life  of  an  animal  inoculated 
with  it 

Behring,  from  the  blood  of  animals  which  had  been  rendered 
immune,  obtained  an  antitoxin  which  is  antagonistic  to  the 
diphtheritic  virus.  The  serum  of  the  horse,  which  has  been 
immunized  by  a,  series  of  diphtheritic  inoculations,  is  used  as  the 
antitoxic  remedy,  both  proph^dactically  and  curatively,  in  the 
treatment  of  diphtheria.  This  serum  has  no  influence  on  the 
bacilli,  but  it  neutralizes  the  toxic  material  which  is  generated 
bv  the  bacilli. 


XXvi  T\TK<^DrOTTON. 

GONOCOCCUS    OK    B.VCTEltlUM    Ol'     GoNORKHCEA. 

The  causal  agent  of  gonorrhoea  is  a  coccus  that  is  triangular 
in  form,  and  usually  two  cocci  are  seen  united  hv  their  bases. 
Several  pairs  are  often  found  clustered  together.  ^  It  is  not  motile. 
This  germ  abounds  in  the  pus  of  gonorrlioeal  ophtiialmia.  The 
gonorrlucal  microbe  is  found  in  the  fluid  of  gleet  so  long  as  the 
disease  is  contagious. 

In  the  lochial  and  blenorrhceal  discliarges  of  the  female, 
bacteria  exist  which  are  similar  in  form  to  the  gonococcus;  yet 
when  these  bacteria  are  subjected  to  the  known  tests  of  differen- 
tiation they  are  found  to  differ  from  the  gonococcus  found  in  the 
pus  of  gonorrhoea. 

Bacillus  of  Glanders. 

This  bacillus  presents  the  form  of  a  slender  rod,  of  which  the 
ends  are  rounded.  It  appears  single  and  not  in  groups,  and  is 
developed  by  spores.  It  is  not  motile,  and  when  dried  it  retains 
its  vitality  for  a  long  time  amidst  the  straw  of  a  stable,  in 
which  a  horse  infected  with  glanders  has  been  housed.  It  easily 
infects  the  mucous  membrane  of  the  nose  of  the  horse,  or  a 
wound  in  the  skin  of  man.     As  yet,  no  remedy  against  glanders 

is  known. 

Bacillus  Coli  Communis. 

Bacteria  are  found  in  the  intestinal  canal,  and  of  these  an 
important  one  is  the  bacillus  coli  communis,  which  is  found  in 
the  bowel  and  itecal  content.  It  is  in  the  shape  of  a  short  rod 
which  is  slow  in  its  movements.  The  normal  mucous  membrane 
of  the  intestine  seems  to  prevent  the  migration  of  this  microbe 
into  the  neighboring  peritoneal  cavity,  but  when  the  mucous 
membrane  loses  its  integrity,  the  bacillus  becomes  a  virulent 
morbific  agent.  And  this  morbid  action  is  more  intense  if  the 
lesion  be  in  the  ileum  than  in  the  jegunum  or  colon.  In  case  of 
intestinal  obstruction,  this  bacillus  is  thought  to  be  the  causal 
agent  of  the  trouble  which  arises.  The  surgeon  is  able  to  render 
aseptic  the  skin  and  the  accessible  mucous  membranes,  but  as 
the  small  intestine  is  beyond  his  reach,  he  can  only  imperfectly 
disinfect  its  interior.  For  this  disinfection  Nussbaum  admin- 
istered chlorate  of  potash.  The  writer  would  give  cam))hor  water, 
cinnamon  water  or  a  decoction  of  capsicunj.  It  is  not  improbable 
that  the  bile  which  is  constantly  being  poured  into  the  intestine 
may  limit  bacterial  development. 

Actinomycosis. 

Actinomyco.sis  is  an  infectious  disease  occuring  primarily  in 
the  ox  and  hog,  and  from   these  animals  the  affection  may  be 


ACTINOMYCOSIS.  XXVI 1 

communicated  to  man.  It  may  attack  the  mouth,  jaws,  tonsils, 
alimentary  canal,  lungs,  and  skin.  It  arises  oftenest  in  the  jaws 
of  animals,  and  the  starting  point  in  them  is  usually  a  decayed 
tooth.  Men  who  have  tlie  care  of  such  diseased  animals  are 
sometimes  infected  with  actinomycosis.  The  inoculation  may 
occur  in  the  mucous  membrane  of  the  mouth,  or  in  the  skin. 
It  begins  as  a  circumscribed,  nodular  induration,  which  finally 
suppurates  and  the  pus  contains  small  yellow  grains  the  size  of 
a  pin's  head,  and  visible  to  tlie  eye.  When  one  of  these  granules 
is  flattened  and  examined  microscopically,  it  will  be  found  to 
contain  star-shaped  figures.  From  the  center  of  these  actinoid 
bodies  proceed  club-like  branches,  and  the  arrangement  of  these 
branches  is  often  such  tliat  the  figure  resembles  a  rosette.  This 
fungoid  parasite  belongs  to  the  family  of  hypomycetes  or 
molds.  It  is  believed  to  develop  by  means  of  spores.  It 
should  be  treated  by  excision,  cauterization,  and  administration 
of  large  doses  of  iodide  of  potassium. 

After  this  brief  description  of  the  chief  bacteriological 
agencies  which  are  recognized  as  the  causal  entities  of  certain 
surgical  affections,  the  subject  of  Antisepsis  and  Asepsis  will  be 
considered,  by  which  the  surgeon  can  prevent  the  admission  of 
bacteria  into  the  field  of  his  opei'ative  work,  or  can  render  those 
inert  which  exist  there.  Should  the  means  known  as  antiseptic 
and  aseptic  be  omitted,  then  a  condition  named  sepsis  arises  in 
the  wounded  structures.  This  is  due  to  the  development  of 
bacteria  and  the  action  of  tlieir  toxic  derivatives  on  the  tissues 
exposed  to  them.  In  the  subject  of  such  morbid  action,  there 
are  increase  of  temperature,  accelerated  heat,  coated  tongue,  and 
diminution  of  the  normal  secretions.  The  patient  is  physically 
ill  at  ease. 

The  doctrine  of  antisepsis  and  its  application  in  the  treat- 
ment of  wounds  originated  with  Joseph  Lister,  about  1870. 
Lister  believed  that  wuunds  w-ere  infected  through  contact  with 
air  which  contained  pathogenic  germs.  And  Jiis  early  treatment 
consisted  in  disinfecting  the  air  in  the  field  of  his  operation. 
And  this  was  done  by  generating  an  antiseptic  spray  or  cloud, 
in  which  both  surgeon  and  ])atient  were  enveloped.  This 
method  was  in  vogue  for  a  period ;  but  it  was  abandoned  when 
it  was  determined  that  the  air  contains  very  few  pathogenic 
microbes;  and  the  few  which  are  thence  derived  may  be 
destroyed  by  phagocytosis,  or  rendered  inert  by  the  cells  of  the 
living  tissues.  Lister's  dressing  of  wounds  was  complex,  and 
consisted,  in  the  main,  of  several  layers  of  gauze  which  were 
permeated  with  carbolic  acid.  Between  this  and  the  wound  was 
interposed  a  layer  of  specially  prepared  oiled  silk,  which   was 


XXVlll  INTRODUCTION 

named  "protective."  The  Listeriaii  method  was  rapidly  adoi)ted 
by  the  younger  generation  of  surgeons;  but  numerous  modifica- 
tions of  it  soon  appeared,  promineut  among  which  was  the 
abandonment  of  the  spray  in  which  Lister  did  liis  early  opera- 
tions. Instead  of  carbolic  acid,  salicylic  acid,  and  boracic  acid 
were  employed  to  impregnate  the  material  used  for  dressing. 
Chloride  of  zinc  in  solution  was  likewise  used.  Sternberg 
deserves  great  credit  for  what  he  has  done  in  the  development  of 
Bacteriology;  he  tested  the  germicidal  power  of  the  various 
antiseptic  agents,  and  found  that  corro.sive  sublimate  is  remark- 
able for  its  anti-bacterial  properties.  As  the  result  of  the  investiga- 
tions of  Sternberg  and  others,  corrosive  sublimate  has  come  into 
general  use  in  both  aseptic  and  antiseptic  surgery.  It  is  used  in 
dilution  varying  in  strength  from  a  solution  of  one  part  in  one 
thousand  parts  of  water  to  one  in  ten  thousand  parts  of  water; 
the  usual  dilution  is  that  of  one  in  two  thousand. 

In  operative  work  done  antisepticall}',  the  surgeon  disinfects 
the  part  to  be  operated  on,  also  his  hands  and  instruments;  and 
this  disinfection  is  done  with  a  carbolized,  sublimated,  or  other 
antiseptic  solution.  It  was  the  custom,  in  the  early  days  of 
antisepsis,  to  flush  the  wound  with  the  antiseptic  solution;  but 
the  antisepticijui  has  modified  this  part  of  his  work,  and  instead 
of  active  chemical  solutions,  he  uses  sterilized  water  for  flushing 
the  wound.  In  thus  doing,  the  operator  avoids  the  irritation  of 
the  wounded  j^arts  wliicli  results  from  the  application  of  carbolic 
acid,  corrosive  sublimate  or  other  chemical  irritant. 

A  few  surgeons  in  operating  closely  follow  the  antiseptic 
metliod  as  first  ]>ursued  by  its  author;  more  deviate  widely  from 
it,  and  have  adopted  a  procedure  known  as  tlie  aseptic.  Asepsis 
is  the  offspring  of  antisepsis.  Asepsis  is  Listerism  simplified.  In 
aseptic  work,  germicidal  chemicals  are  withheld  from  the  wounded 
structure. 

To  do  an  operation  asepticall}^  the  surgeon's  hands  should  be 
absolutely  clean,  his  operating  dress  clean  through  sterilization, 
his  instrnments  purified,  the  surface  to  be  operated  on  must  be 
purified  from  bacteria  and  their  derivative  toxins.  And  finally, 
the  work  being  done,  a  dressing  must  be  applied  which  will 
exclude  every  infective  agency. 

To  cleanse  the  hands  and  forearms  let  them  be  scrubbed  well 
with  Castile  or  green  soap  and  water,  which  has  been  sterilized  by 
boiling.  A  brush  which  has  been  sterilized  by  immersion  in 
chloroform,  alcohol,  or  turj)entine  must  be  used  on  the  nails, 
fingers,  and  hands.  The  hands  should  then  be  rubbed  with 
alcohol,  and,  lastly,  immersed  in  a  solution  of  sublimate.  An- 
other plan,  after  the  hands  have  been  cleansed  with  soap  and 
water,  is  to  immerse  them  in  a  solution  of  permanganate  of 
potash,  then  to  decolorize  them  in  a  solution  of  oxalic  acid,  and 
to  conclude  by  immersing  them  in  a  solution  of  sublimate. 
Another  plan  is  to  take  equal  parts  of  chloride  of  lime  and 
carbonate  of  soda,  and  having  made  a  paste  of  them  to  rub  tliis 


ACTINOMYCOSIS.  XXIX 

on  the  bauds  which  have  been  cleansed  with  soap  and  water, 
and  to  conclude  by  washing  this  off  with  sterilized  water.  The 
writer's  plan  is  to  scrub  the  hands  well  with  soap  and  water, 
and  then  to  rub  them  well  with  pure  alcohol,  or  instead  of 
alcohol,  chloroform  may  be  used  as  the  final  application  to  the 
hands. 

The  operator  should  wear  a  rubber  apron  to  protect  his  dress, 
and  over  this  a  sterilized  linen  or  cotton  gown  sliould  be  worn. 
Instruments  can  be  purified  by  inclosure  in  an  oven  or  closed 
vessel,  which  is  heated  to  a  high  temperature.  The  steel  of 
instruments,  however,  is  softened  or  changed  by  a  high  heat; 
hence  other  methods  of  sterilization  have  been  introduced. 
That  of  Schimmelbusch  is  often  used,  which  consist  in  immers- 
ing them  in  a  strong  solution  of  bicarbonate  of  soda,  and  boiling 
them  in  this  for  fifteen  minutes.  Another  plan  is  to  immerse  the 
instruments  in  a  four  per  cent  solution  of  carbolic  acid,  and 
afterwards  w^ash  them  in  sterilized  water.  And  during  the 
operation  the  instruments  may  remain  immersed  in  a  twenty- 
five  per  cent  solution  of  alcohol. 

The  skin,  especiall}'  the  hair  and  sebaceous  follicles,  are  the 
special  habitats  of  bacteria,  hence  dermal  purification  is  a  most 
important  prcliminarv  to  an  operation.  And  the  first  step  in 
this  is  a  general  bath,  in  which  the  patient's  body  is  cleansed 
with  soap  ai)d  water.  The  part  to  be  operated  on  is  to  be  shaven, 
and  then  turpentine  rubbed  on  it,  and  the  work  to  conclude  by 
diligently  washing  with  soap  and  water.  And  if  the  pleural  or 
]-)eritoneal  cavity  is  to  be  opened,  besides  the  disinfection  men- 
tioned, a  soap  poultice  may  be  worn  for  twelve  hours  prior  to  the 
contemplated  operation.  The  part  to  be  operated  on  should  be 
surrounded  with  sterilized  sheets. 

The  material  for  ligating  vessels  may  be  of  silk  or  catgut. 
Silk  can  be  sterilized  by  boiling  it  in  water,  or  by  prolonged 
immersion  in  alcohol.  Catgut  is  sterilized  in  several  ways:  this 
may  be  done  by  boiling  in  alcohol,  or  by  prolonged  immersion 
in  an  alcoholic  solution  of  corrosive  sublimate,  viz.,  one  of  sub- 
limate to  five  hundred  of  alcohol,  and  afterwards  the  thread  is  to 
be  retained  in  alcohol.  Some  prepare  it  by  treatment  with 
formalin,  and  others  with  cnmol.  Catgut  may  he  hardened,  and 
rendered  less  absorbable  by  boiling  in  a  dilute  solution  of  chromic 
acid  in  carbolized  water. 

Silk-worm  gut  is  used  for  external  sutural  closure.  It  is 
disinfected  by  prolonged  immersion  in  ether,  and  it  should  be 
preserved  in  alcohol. 

Silver  wire,  or  copper  wire  well  plated  or  gilded,  may  be 
used  for  suture.  Wire  can  be  purified  by  immersion  in  boil- 
ing water,  an-l  it  is  best  closed  by  twisting  instead  of  tying. 
Unlike  silk  or  catgut,  metallic  suture  does  not  swell  or  enlarge 
in  the  tissues. 

If  the  dermal  lips  of  the  wound  be  too  far  asunder  for  sutural 
approximation,  then  the  wounded  surface  should  be  closed  by 


XXX  INTHODrCTION. 

the  dermo-epidermal  grafts  of  Thiersch  as  described  elsewhere  in 
this  book. 

The  wouud  may  or  may  not  be  drained  according  to  its 
condition:  if  the  raw  cavity  be  well  cleansed,  and  there  be  no 
probability  of  etfnsion  of  blood,  serum,  or  of  infected  excrementi- 
tial  matter,  then  complete  closure  may  be  done.  In  case  ihe 
wound  be  infected,  or  blood  or  scrum  will  probably  be  effused 
into  it,  then  drainage  should  be  established  b}' sterilized  catgut, 
rubber  tubing,  or  iodoform,  or  other  aseptic  gauze. 

The  sutural  closure  being  completed,  the  remaining  seam  may 
be  painted  with  the  compound  tincture  of  benzoin.  This  agent 
is  especially  useful  where  the  operation  is  done  on  a  mucous 
surface,  or  on  the  skin  near  the  mouth,  nostrils,  or  eyes,  whence 
excreta  can  flow  and  come  in  contact  with  the  wound.  Tincture 
of  benzoin  quickly  forms  an  imi)ermeable  varnish,  which  acts 
both  occlusivel}'  and  antiseptically. 

The  wound  is  next  to  be  covered  with  several  layers  of 
sterilized  gauze,  and  an  outer  layer  of  absorbent  cotton.  Cotton 
in  some  unknown  way,  insures  against  the  penetration  of 
bacteria ;  and  owing  to  this  property  of  cotton,  Guerin  obtained 
excellent  results,  as  the  writer  was  witness  of,  from  the  use  of 
cotton  wadding  as  a  dressing  of  compound  fractures. 

The  sterilized  gauze  may  be  prepared  from  cheese-cloth, 
tarletan,  or  other  meshed  cloth,  by  boiling  it  in  a  solution  of 
soda,  and  afterwards  saturating  it  with  a  berated  or  sublimated 
solution  ;  and  after  this  preparation,  it  may  be  preserved,  moist 
or  drv,  in  a  closed  vessel.  A  gauze  that  is  in  common  use,  is  one 
which,  after  being  sterilized  by  boiling  or  steam,  is  saturated  with 
iodoform. 

After  the  wound  has  been  dressed  with  gauze,  the  latter  may 
be  covered  with  absorbent  cotton,  and  the  whole  fixed  in  place  by 
a  retaining  bandage. 

The  wound  dressed  in  the  way  described  may  remain  undis- 
turbed for  a  week  or  more,  provided  there  be  no  rise  of  the 
patient's  temperature,  and  then,  on  the  removal  of  the  dressing, 
the  wound  will  be  found  healed.  Such  are  the  results  which  are 
obtainable  in  a  surgical  operation  which  has  been  executed 
without  fault  or  lapse  in  all  the  details  of  asepsis.  Should 
the  wound,  however,  not  have  this  satisfactory  termination,  of 
which  the  surgeon  would  have  a  foretoken  in  the  rise  of  tempera- 
ture, then  the  dressing  should  be  removed,  and  such  corrective 
measures  taken  as  the  conditions  indicate. 


CHAPTER  I. 


SURGERY    OF    THE    SCALP. 


Hippocrates  fully  appreciated  the  gravity  of  affections  of  the 
head,  and  especially,  of  the  wounds  of  the  head.  Several  chapters 
of  the  works  under  his  name  which  have  reached  us  are  devoted 
to  wounds  of  the  cranium,  and  create  in  the  reader  admiration 
of  the  progress  and  knowledge  which  had  then  been  reached  in 
this  direction.  In  several  editions  of  the  divine  old  max,  as 
Hippocrates  is  often  reverentl}''  named,  this  famous  sentence 
occurs:  "Nullum  vulnus  capitis  contemnenduvi  est;  "  or,  as  our  tongue 
would  have  it,  "  Xo  wound  of  the  head  is  to  be  viewed  as  a  trifling 
matter."  If,  as  Littre  thinks,  this  phrase  is  an  interpolation  by 
some  later  transcriber,  yet  there  is  so  much  practical  wisdom 
couched  in  it  that,  rather  than  expunge,  we  should  be  grateful 
for  the  interpolation,  for  the  practitionCT  of  surgery  can  have 
no  more  valuable  rule  for  his  faithful  observance  and  constant 
guidance  than  that  every  wound  of  the  head  should  receive 
careful  and  thoughtful  treatment.  With  this  prefatory  prelude, 
we  will  proceed  to  a  brief  study  of  the  surgical  anatomy  of  the 
scalp,  necessary  to  a  proper  understanding  of  the  diseases  and 
injuries  to  which  the  scalp  is  subject. 

surgical  anatomy  of  the  scalp. 

Some  knowledge  of  the  parts  that  enter  into  the  structure  of 
the  scalp  is  necessary  to  enable  one  to  intelligently  study  morbid 
and  traumatic  conditions  which  occur  here.  As  component 
elements  of  the  minuter  species,  one  finds  squamous  or  flat 
epithelial  cells,  connective  ti.ssue  and  adipose  cells,  and  muscular, 
fibrous,  nervous, vascular,  and  lymphatic  structures.  Each  of  these 
components,  whether  cellular  or  structural,  performs  an  important 
part  in  the  attendant  phenomena  of  the  wounds  of  the  scalp, 
especially  the  epithelial  and  connective  tissue  cells  and  the 
vessels.  The  scalp  is  divisible  into  stratified  aggregated  struc- 
tures of  larger  order  than  the  preceding  ones  mentioned.     Com- 

(7) 


S  Sl'KGKRY    OF    TIIK    SCAI.I'. 

mencing  outwards  and  i)assing  inwards,  tliese  layers  rest  on  each 
other  in  the  following  order,  the  cutaneo-adipose,  the  aponeurotic, 
and  the  periosteal.  The  outer  one  is  constituted  of  the  derm 
and  fatty  couch,  and  is  especially  important,  since  from  it  proceeds 
the  hair,  and  in  it  are  contained,  also,  the  sebaceous  and  sudo- 
riferous glands  and  the  vessels. 

This  first  layer  is  especially  conspicuous  as  the  ground  in 
which  the  hair  grows.  In  it  the  hair  roots  are  planted,  reaching 
often  quite  through  the  derm,  and  thou  resting  on  the  .subjacent 
fatty  couch.  This  fatty  layer,  it  may  be  renuirked,  is  so  closely 
adherent  to  the  derm  that  it  requires  a  forced  dissection  to 
separate  the  two.  The  fat  is  lodged  in  ovoidal  compartments, 
the  wall-like  partitions  being  composed  of  dense  fibrous  tissue. 
It  can  only  be  removed  from  the  skin  by  careful  scraping,  where 
the  under  surface  of  the  derm  will  present  a  figured  appearance. 
The  roots  do  not  penetrate  vertically,  but  obliquely,  so  that  the 
hairs,  as  a  rule,  tend  to  lie  flatwise,  with  shafts  diverging  from, 
and  roots  converging  towards,  the  so-called  crown,  or  posterior 
fontanel,  of  the  skull.  This  cutaneo-adipose  layer  increases  in 
thickness  as  one  passes  from  before  backwards.  With  advancing 
years,  the  hair  on  the  upper  part  of  the  scalp,  through  atrophy 
of  the  blastema,  wheyce  tlie  individual  hair  grows,  gradually 
falls.  At  the  same  time  this  portion  of  the  scalp  becomes  atten- 
uated through  the  vanishing  of  the  adeps  contained  in  the 
outer  stratum.  This  senile  attenuation  has  a  bearing  in  surgical 
work.  The  traversing  scalpel  creaky  as  it  goes,  and  demands 
greater  efifort  to  open  its  path  than  is  the  case  in  the  structures 
of  the  younger  subject. 

The  cutaneo-adipose  layer  is  remarkable  for  its  richness  in 
vessels,  which  are  found  here  in  greater  multitude  than  on  any 
other  part  of  the  surface  of  the  body,  excei:)t  that  of  the  surface 
of  the  ends  of  the  toes  and  fingers;  and,  as  on  the  ends  of  the 
fingers,  the  vessels  in  the  skin  of  the  scalp  lie  ver}^  superficial. 
As  Tillaux  has  specially  pointed  out,  the  vessels  of  the  scalp  lie 
in  the  skin  and  fatty  stratum,  and  not  beneath  it,  as  is  the 
arrangement  elsewhere:  for  the  usual  anatomical  disposition  is 
that  vessels  near  the  periphery  lie  in  the  subcutaneous  fascia. 
In  the  scalp,  however,  they  are  quite  external  to  this  structure. 

In  the  cutaneo-adipose  layer  are  numerous  sebaceous  and 
sudoriferous  glands.  The  occlusion  of  the  outlets  of  the  sebaceous 
glands  gives  rise  to  the  atheromatous  or  sebaceous  cysts  often 
found  in  the  scalp. 


SURGICAL    ANATOMY    OF    THE    SCALP.  9 

The  second  important  stratum  is  the  so-called  aponeurosis 
or  musculo-fibrous  layer,  which,  like  an  arched  bridge,  rests  on 
the  cranial  vault,  from  before  backwards.  In  the  frontal  and 
parietal  regions  it  is  reenforced  by  muscular  fibres,  the  whole  of 
these  forming  the  occipito-fron talis  muscle.  From  its  firm,  dense, 
and  protective  character  arose  the  name  galea  capitis,  or  helmet 
of  the  head.  In  the  lateral  regions  of  the  head  this  aponeurosis 
becomes  attenuated  to  a  layer  of  less  thickness,  corresponding 
more  to  subcutaneous  fascia  elsewhere. 

This  aponeurosis  of  musculo-fibrous  structure  is  so  closely 
adherent  to  the  cutaneo-adipose  layer  outside  that  they  can  only 
be  separated  by  a  forced  dissection.  From  it  spring  the  fibrous 
partitions  which  separate  and  inclose  the  fat  cellules,  and  then 
fuse  with  the  external  derm.  In  its  vascularity  this  stratum 
presents,  in  an  unusual  degree,  a  numerical  superiority  of  the 
venules  over  their  corresponding  arterioles.  The  consequent 
slackening  of  the  circulation  resulting  from  this  disposition 
throws  some  light  on  morbid  conditions  which  occur  here.  This 
musculo-fibrous  stratum  is  closely  adherent,  as  has  been  stated, 
to  the  layer  external  to  it,  but  is  very  loosely  connected  to  the 
periosteal  stratum  which  lies  inside  of  it,  namely,  there  is  an 
interval  between  it  and  the  subjacent  stratum,  occupied  only  by 
loose  connective  tissue.  The  result  is  that  the  closely  cohering 
first  and  second  layers  are  readily  movable  on  the  third  or  inner- 
most stratum,  and,  due  to  such  laxity,  the  outer  portion  of  the 
scalp  can  be  moved  backwards  and  forwards  at  will,  by  certain 
persons.  This  space  external  to  the  periosteum  is  of  such  a 
character  that  it  is  almost  serous  or  bursal  in  structure,  and  it 
furnishes  ready  lodgment  for  pus,  extravasated  blood,  and  oedem- 
atous  accumulations.  As  a  consequence  of  the  existence  of 
this  space  the  scalping  knife,  as  well  as  that  of  the  necropsist, 
can  the  more  readily  detach  the  scalp,  and  due  to  it  the  lacerated 
wound,  also,  may  reach  great  dimensions. 

The  third  layer,  which  must  be  reckoned  as  the  innermost 
portion  of  the  scalp,  is  the  periosteum,  named  here,  from  its 
position,  the  pericranium.  This  pericranial  layer  is  thicker  than 
the  periosteum  elsewhere,  and  contains  blood-vessels  and  nerves. 
The  unusual  number  of  nerves  renders  the  membrane  sentient 
and  the  seat  of  neuralgic  trouble.  The  vascularity  varies  with 
age,  becoming  more  limited  in  advancing  years,  yet  in  the  young 
subject  Hyrtl  has  found  through  injections  that  there  is  a  direct 
connection  between  the  intra-cranial  vessels  of  the  dura  mater 


10  SURGERY    OF    THE    SCALP. 

and  the  pericranium.  Material  injected  into  the  middle  menin- 
geal artery  traverses  the  cranial  wall  of  the  child,  and  appears 
in  the  external  periosteum.  And  in  this  way  the  encephalic  en- 
gorgement of  the  child  finds  a  medium  for  partial  escai)e.  But 
later  in  life  osseous  condensation  obliterates  these  minute  vessels. 
And  as  this  obliteration  proceeds,  death  of  the  bone  can  more 
readily  occur.  As  a  result  of  sucli  vascularity,  and  the  facility 
for  afflux  and  efflux  of  blood,  cranial  necrosis  is  rare  in  the  young- 
subject. 

The  pericranium  is  adherent  to  the  sutures  of  the  cranium, 
and  somewhat  so  to  the  frontal  and  parietal  eminences;  elsewhere 
the  connection  is  slight,  so  that  the  membrane  can  easily  be 
detached  from  the  adjacent  bone.  The  adherence  of  the  peri- 
cranium to  the  skull  is  closer  and  firmer  than  is  the  adhesion  of 
the  pericranium  to  the  overlying  musculo-aponeurotic  layer. 
Hence  in  the  wound  made  for  trephining,  unless  these  conditions 
be  well  borne  in  mind,  the  uplifted  flap  will  leave  the  periosteal 
layer  behind. 

The  arteries  of  the  scalp  are  derived  from  the  external  carotid, 
except  those  which  are  distributed  to  i»arts  within  the  orbit,  or 
which  emerge  from  this  cavity,  as  the  supra-orbital,  frontal  and 
nasal,  and  also  a  few  which  traverse  the  cranial  foramina:  in  all 
these  excepted  cases  they  emanate  from  vessels  within  the  cranium, 
and  chiefly  from  the  internal  carotid  artery. 

The  arteries  found  in  the  scalp  are  the  following:  frontal, 
supra-orbital,  temporal,  auricular  and  occipital. 

The  frontal,  which  furnishes  blood  to  the  pedunculated  flap 
taken  from  the  forehead  in  rhinoplastic  operations,  done  according 
to  the  Indian  method,  lies  from  a  quarter  to  a  third  of  an  inch 
from  the  median  line;  hence,  if  the  pedicle  of  the  twisted  flap  have 
a  breadth  of  a  half  inch,  it  will  certainly  contain  one  of  the  frontal 
arteries,  and  therefore  its  nutrition  will  be  insured. 

The  temporal  artery  is  the  posterior  one  of  the  two  branches 
into  which  the  external  carotid  divides,  when  it  has  ascended 
into  the  upper  part  of  the  parotid  gland.  This  division  into  the 
temporal  and  internal  maxillary  branches  occurs  in  front  of  the 
tragus,  and  in  the  angle  formed  by  the  condyloid  process  of  the 
lower  jaw  and  the  zygoma  of  the  tem|)oral  bone.  After  rising 
nearly  an  inch  above  the  zygoma,  the  temporal  becomes  super- 
ficial, and  divides  into  two  branches,  the  anterior  and  posterior 
temporal  arteries.  These  vessels.,  quite  visible  to  the  eye,  become 
tortuous  with  age.     Just  previous  to  the  division  of  the  primary 


SURGICAL    AJSATOMY    OF    THE    SCALP.  11 

trunk,  it  gives  off  a  branch  named  the  deep  or  middle  temporal, 
which  dips  down  through  the  superficial  fascia  to  the  bone,  and 
thence  lying  in  a  furrow  on  the  squamous  portion  of  the  temporal 
bone,  it  ascends  nearly  straight  upwards  towards  the  summit  of 
the  skull;  the  course  of  this  deep  temporal  artery  corresponds 
pretty  nearly  to  a  line  drawn  vertically  upwards  from  the  external 
auditory  meatus,  as  may  be  verified  by  one  unwittingly  opening 
it,  as  once  occurred  to  the  author  in  lancing  an  abscess  in 
this  region.  In  front  of  the  middle  temporal  lies  the  posterior 
superficial  branch,  which  mounts  upwards  to  near  the  summit  of 
the  head.  The  anterior  superficial  branch  is  distributed  to  the 
integument  on  the  side  of  the  forehead.  The  branches  of  the 
temporal  artery  are  often  the  subjects  of  wounds,  and  in  former 
times  when  arteriotomy  was  resorted  to  for  disease  of  the  eye, 
these  arteries  were  often  attacked.  The  service  of  the  lance  here 
has  been  superseded  by  that  of  the  suction-cupping  cylinder,  and 
other  improved  methods  of  the  oculist. 

Another  artery  deserving  attention  is  the  posterior  auricular, 
which  in  its  origin  lies  under  the  edge  of  the  parotid  gland.  It 
soon  reaches  and  lies  in  the  sulcus  between  the  pinna  and  the 
mastoid  portion  of  the  temporal  bone.  Yet  abscess,  which  often 
appears  here,  lifts  the  vessel  from  its  deep  sub-aponeurotic  site,  so 
that  it  becomes  (as  Tillaux  says)  interested  in  the  lancing  of  such 
abscess.  From  dissections  made  by  the  author,  the  vessel  in  the 
normal  state  of  the  parts  lies  deep  on  the  bone,  so  that  in  plastic 
work  done  to  reconstruct  the  adjacent  part  of  the  ear,  a  flap  may 
be  uplifted  without  risk  of  wounding  the  posterior  auricular 
vessel. 

The  disposition  and  situation  of  the  lymphatic  vessels  and 
glands  of  the  scalp  merit  more  attention  than  is  commonly  given 
them.  These  vessels,  from  their  minuteness  and  want  of  color, 
often  pass  unnoticed,  or  are  mistaken  by  the  dissector  for  con- 
nective tissue.  As  channels  for  the  metastatic  transmission  of 
septic  or  infectious  material,  these  parts  are  of  extreme  importance. 
The  glands,  when  swollen,  point  unmistakably  backward  to  some 
infected  point  along  the  course  of  their  different  vessels,  and  then 
become  important  aids  in  diagnosis. 

The  lymphatics  commence  by  a  close  network  of  fine  vessels 
along  the  median  or  sagittal  plane  of  the  scalp.  This  capillary 
network,  discoverable  by  injection  in  the  young  child,  lies  very 
superficial  in  the  skin.  From  it  depart  toward  each  side  groups 
of  vessels,  which,  according  to  their  destination,  may  be  named 


12  SURGERY    OF    THE    SCALP. 

frontal,  parietal,  and  occipital  lymphatics.  These  vessels  (juickly 
abandon  their  superficial  situation,  and  penetrate  so  deeply  into 
the  skin  that,  unlike  what  occurs  elsewhere,  when  they  become 
inflamed  they  cannot  be  seen  as  red  lines. 

The  frontal,  or  anterior  series,  passes  downwards  and  back- 
wards and  enters  two  or  three  glands  which  lie  in  or  on  the  parotis, 
near  to  the  condyle  of  the  lower  jaw.  Lymphatics  of  the  parot- 
idean  region  enter  these  glands;  hence  swelling  of  the  glands, 
though  it  may  point  to  disease  on  tlie  forehead,  might  also  indi- 
cate disease  or  lesion  on  the  side  of  the  face  or  eyelids.  These 
glands  have  also  connection  with  others  which  lie  below,  near 
the  angle  of  the  lower  jaw. 

The  second,  or  parietal  group  of  lymphatics  are  of  larger 
volume  than  the  frontal,  pursuing  a  downward  course,  almost 
straight  in  direction,  to  two  or  three  glands  which  lie  on  the  origin 
of  the  sterno-cleido-mastoid  muscle,  over  the  mastoid  process; 
and  from  these  glands  efferent  lymphatics  proceed  to  the  super- 
ficial and  deep  cervical  glands. 

The  third  group  named,  occipital,  pass  downwards  and  back- 
wards to  the  occipital  glands,  one  or  two  in  number,  which  lie  on 
the  origin  of  tiie  trapezius  muscle. 

The  parietal  and  occipital  lymphatics  so  interlace  and  inter- 
communicate that  they  may  be  regarded  almost  as  one  system. 
In  consequence  of  such  inosculation,  it  is  probable  that  when  one 
or  more  branches  become  obstructed,  their  contents  may  find 
escape  through  contiguous  branches. 

Tlie  glands  wliich  as  a  broken  chaplet  clasp  the  posterior 
part  of  the  head  near  its  base,  are  so  often  affected  in  secondary 
syphilis  that  Ricord  proposes  to  feel,  in  the  back  of  the  neck,  the 
pulse  of  the  syphilitic  subject.  More  properly,  however,  these 
glands  are  like  signs  which  point  back  and  indicate  the  course  of 
the  afferent  lymphatics. 

The  nerves  of  the  scalp,  functionally  considered,  are  of  three 
kinds:  Motor,  from  tlie  facial,  few  in  number;  jnirely  sensory, 
from  the  fifth  pair;  and  also  those  of  mixed  functions.  Of  these 
three,  the  purely  sensory  nerves  are  those  which  require  notice 
here;  for  as  these  are  the  site  of  neuralgic  pains,  along  with 
others  of  their  order,  they  sometimes  become  the  subjects  of 
operation. 

From  the  ophthalmic  branch  of  the  fifth  pair  proceeds, 
within  the  orbit,  the  frontal  nerve,  which,  lying  close  to  the 
upper  wall  of  the  orbit,  escapes  with  a  small  artery  through  the 


SUHGICAL   ANATOMY    OF   THE   SCALP.  13 

supra-orbital  notch,  and  passes  thence  upwards  on  the  forehead. 
Within  the  orbit  there  are  given  off  some  small  branches,  an 
important  one  of  which  is  a  small  twig  which  penetrates  and 
ascends  within  the  frontal  bone,  and  it  ends  or  escapes  at  the 
frontal  eminence ;  this  filament,  escaping  neurotomy  or  neurec- 
tomy of  the  frontal  nerve,  explains  the  continuance  of  pain  after 
these  operations. 

After  this  preliminary  consideration  of  the  structures  of  the 
scalp  that  especially  fall  within  the  province  of  surgery,  we  will 
now  proceed  to  a  study  of  the  surgical  diseases  of  this  region. 


CIIAPTEI'v  IT. 

GEXEKAL  CLASSIFICATION  OF  THE  AFFECTIONS  OF  THE  SCALP,  FOL- 
LOWED BY  A  CONSIDERATION  OF  INFLAMMATION  AND  OTHER 
MATTERS  WITHIN  THE  SPHERE  OF  GENERAL  SURGICAL  PA- 
THOLOGY. 

The  interminable  variety  of  diseases,  to  which  additions  are 
being  made  by  the  legitimate  progress  of  medicine,  and  especially 
by  the  ambition  of  those  who  are  desirous  of  fame  as  contributors 
to  nomenclature,  is  perplexing  to  both  teacher  and  learner.  To 
lessen  tlie  lalxn*  of  mastering  such  detail,  considerate  writers  seek 
to  epitomize  and  to  clearly  generalize,  and  thus  to  lessen,  as  much 
as  possible,  by  mnemonic  aids  the  tasks  of  their  readers.  With 
such  purpose  the  following  categories  and  groups  of  disease  which 
are  met  within  the  cranial  integuments  are  presented: — 

1.  Inflammation,  traumatic  or  specific,  as  seen  in  erysipelas; 
or  in  a  furuncle,  abscess,  carbuncle,  diffused  phlegmon,  or  ulcer; 
or  in  the  more  simple  forms  of  skin  disease,  as  acne,  eczema,  etc. 

2.  Gangrene,  ulcers  and  fistula. 

3.  Syphilitic,  scrofulous  and  tubercular  disease  in  their  local 
manifestations. 

4.  Injuries,  in  which  are  comprised  the  various  forms  of 
wounds,  viz., incised  and  flap  wounds;  penetrating,  lacerated  and 
contused  wounds,  wounds  caused  by  gunshot  and  the  diverse 
missiles  used  in  war. 

5.  Burns  and  inj  ury  from  contact  of  acids  and  caustic  alkalies. 
G.  Hypertrophy  and  atroph}'. 

7.  Tumors,  benign  and  malignant. 

8.  Aneurism. 

9.  Arterio-venous  enlargement  and  varix. 

10.  Oedema. 

11.  Emphysema. 

12.  Neuralgia. 

It  is  the  plan  of  this  work   to  intermingle   the   subjects  of 
surgical  anatomy,  special  and  general  surgery,  in  such  a  manner 
(14) 


INFLAMMATION.  15 

that  each  may  add  to  the  interest  of  the  other;  by  following  out 
such  a  course  it  is  hoped  to  maintain  an  enlivening  variety  of 
matter,  and  thus,  as  far  as  possible,  to  avoid  tedious  monotony. 
And  though  in  following  such  a  plan  the  rigidly  scientific  method 
may  be  the  loser,  yet  it  is  expected  that  the  reader  will  be  the 
gainer. 

If  precedent  be  sought  for  such  deviation,  the  waiter  finds  one 
in  the  example  of  Joseph  Hyrtl,  in  whose  admirable  work  on 
"Topographical  Anatomy"  one  finds  a  violation  of  the  prescribed 
rules  of  treating  this  subject;  yet  Hyrtl's  transgression,  though 
chastised  by  Grerman  critics,  has  given  medicine  a  work  of  which 
each  page  interests  the  reader,  and  clings  to  his  memory;  should 
these  pages,  though  they  violate  wonted  method,  awaken  a  tithe 
of  such  interest  the  writer's  task  will  be  well  rewarded. 

INFLAMMATION. 

The  subject  of  inflammation,  which,  as  above  mentioned,  is 
present  in  some  of  the  affections  of  the  scalp,  demands  an  early 
and  important  page.  xA.nd  this  importance  is  augmented  when 
it  is  considered  that  this  subject  is  shared  equally  by  surgery  and 
internal  medicine.  It  has  engaged  the  study  of  a  Billroth,  a 
Weber,  a  Chauvel  in  surgery  quite  as  much  as  a  John  Simon 
and  Virchow  in  internal  medicine.  This  list  of  names  (in  which 
many  others  might  have  been  included),  represents  some  of  the 
best  intellects  which  by  their  labors  have  advanced  medicine  in 
modern  times.  The  subject  has  become,  as  it  were,  a  scientific 
arena  in  which  cultivated  minds  have  worked  ambitiously,, 
hoping  to  win  laurels  by  solving  some  difficult  problem,  or  by 
making  some  new  discovery.  Until  within  recent  years,  the 
student  of  inflammation  confi.ned  his  researches  to  the  laboratory 
of  his  brain.  The  modern  investigator  has  chosen  the  inductive 
method  of  vivisection ;  and  in  this  latter  work,  the  frog,  guinea 
pig,  pigeon,  dog,  and  other  animals  have  become  important 
coadjutors. 

The  Latin  tongue,  which  long  prior  to  our  civilization 
passed  from  the  rude  and  concrete  stage  to  the  abstract,  has  left 
us  a  treasure  in  the  writings  of  Celsus;  and  to  the  lovers  of  classic 
literature,  no  more  charming  work  can  be  commended  for  study 
than  that  of  this  old  author.  And,  though  it  remains  a  matter  of 
controversy  whether  Celsus  ever  practiced  medicine,  yet  every 
one  of  his  readers  becomes  quickly  convinced  of  the  practical 
value  of  his  teaching.     Celsus  has  left  us  a  definition  of  iuflam- 


16  AIM'KCTIOXS    OK    THE    SUALP. 

niation  that  is  remarkul)lo  for  brevity,  as  well  as  wide  range  of 
meaning.  The  four  words  of  this  definition,  redness,  swelling,  Jteat, 
and  jmhi,  have  been  named  the  Celsian  (quadrangle ;  and,  altiiough 
these  corner  stones  were  laid  eighteen  hundred  years  ago,  they 
endure  until  to-day;  and  on  them  the  modern  l)uilders  yet  build. 
As  proof  of  this,  the  following  definitions  of  infiammation  given 
in  recent  times  are  presented.  Says  Otto  Weber,  an  eminent 
German  student  of  surgical  pathology,  "  Inflammation  is  a  local 
disturbance  of  nutrition  caused  by  an  irritant;  this  disturbance 
commences  with  augmented  formative  action  and  is  attended  by 
an  increased  afflux  of  nutritive  material  to  the  part,  as  well  as  by 
increased  disintegration."  Strieker,  another  medical  authority  of 
eminence,  defines  it  to  be  "a  wound,  disturbance  of  circulation, 
exudation  of  fluid  and  solid  matter,  disturbed  nutrition,  and  new 
growth."  The  author  ventures  to  offer  a  kindred  one:  in  inflam- 
mation there  is  an  increased  afflux  of  blood  or  plasma  to  a  part 
as  agents  of  ascending  metamorphosis;  also  an  increased  efflux  of 
elements  resulting  from  disintegration,  as  the  result  of  retrograde 
metamorphosis,  the  whole  originating  from  a  local  irritant.  Se'e, 
a  French  writer,  says  that  "  inflammation  consists  of  tumultuous 
acts,  nutritive  and  innutritive;  it  is  an  image  of  nutrition  in  which 
equilibrium  is  broken." 

According  to  Heurtaux,  a  diligent  student  of  this  subject, 
inflammation  is  a  disturbance  of  nutrition  inducing  a  reversion 
to  the  embryonic  type  of  tissue,  and  a  production  of  plastic 
material,  and  sometimes  of  pus;  the  resulting  lesions  are  transient 
and  leave  no  trace;  or  they  are  destructive;  or  they  may  aid  in 
the  formation  of  connective  tissue;  of  the  eventualities  here 
enumerated,  one  or  more  may  be  absent.  And  this  inconstancy 
depends  on  the  fact  that  the  process  may  stop  and  retrograde. 

Now  if  the  leading  points  of  these  definitions  be  note,d,  we 
are  able,  by  a  slight  interpretation,  to  discover  in  them  that  of 
Celsus;  we  have  a  resemblance  to  a  palimpsest,  or  old  manu- 
script, in  which  the  first  writer's  text  can  be  re-read  througli  the 
lines  of  the  second  one.  The  modifications  in  nutrition  which 
inflammation  induces  in  a  part  are  the  chief  phenomena  which 
eighteen  centuries  have  added  to  our  knowledge.  And  even  the 
processes  concerned  in  nutrition  are  so  far  from  being  clearly 
known  that  the  term  itself  is  more  a  name  than  a  thing  clearly 
understood.  If  to  the  Celsian  definition  we  add  the  term  modified 
function  then  it  becomes  supplemented  with  about  the  only  impor- 
tant addition  that  modern  research  has  given  us.     Our  Celsian 


INFLAMMATION.  17 

definition  being  thus  completed,  we  will  proceed  now  to  an 
elucidation  of  its  component  factors,  and  will  begin  with  that  of 
rubor,  or  redness. 

When  a  part  of  the  body  is  irritated,  the  vessels  which  traverse 
it  momentarily  contract  and  then  they  dilate  and  remain  swollen ; 
but  if  the  part  be  non-vascular,  as  cartilaginous  or  corneal  struc- 
ture, then  the  contiguous  or  circumambient  vessels  undergo  like 
changes,  the  result  in  both  cases  being  that  the  redness  of  the 
parts  is  increased  as  soon  as  the  second  act,  or  swelling  of  the 
vessels,  has  ensued.  As  causes  of  the  consecutive  contraction  and 
dilation  of  the  vessels,  investigators  differ;  one  class  invokes  an 
occult  intervention  on  the  part  of  the  nerves;  another  class  locates 
the  action  exclusively  in  the  muscular  tunic  of  the  capillaries, 
which,  for  an  instant,  contract  and  then  expand  through  exhaus- 
tion. The  only  act  usually  visible  is  the  widening,  manifested 
by  the  redness  of  the  part.  The  tegument  of  the  affected  part 
has  some  influence  on  the  degree  of  redness;  when  thin,  as  in  the 
cuticle  of  the  skin  when  attenuated,  or  in  the  covering  of  the 
mucous  membrane  of  the  mouth,  the  redness  is  increased.  But 
when  the  epidermis  is  thick,  as  on  the  soles  of  the  feet,  then  the 
inflamed  condition  of  the  underlying  structures  may  not  be 
apparent  on  the  surface.  Again,  the  presence  of  redness  in  a 
part  of  the  living  or  dead  body  may  be  due  to  physical  causes; 
for  example,  it  may  be  dependent  on  gravitation  or  obstruction 
to  the  escape  of  blood  from  the  part,  and  thus  the  observer  can  be 
misled.  A  notable  example  of  this  may  be  cited  to  serve  as 
a  warning  against  falling  into  such  error.  Broussais,  of  the 
Parisian  school  of  medicine,  distinguished  for  both  frailty  and 
brilliancy  of  intellect,  announced  that  he  had  discovered  the 
pathological  key  to  many  diseases  in  an  inflammation  of  the 
coats  of  the  stomach.  This  doctrine  was  founded  on  the  fact  that 
he  found  in  all  the  autopsies  which  he  made  or  observed,  redness 
of  the  mucous  lining  of  the  stomach.  The  position  of  the  portal 
system  of  vessels,  so  intercalated  between  the  vessels  and  arterial 
capillaries  of  the  systemic  vessels  as  to  permit  congestion  as  the 
cardiac  force  is  lessening,  was  overlooked  by  this  author,  and  this 
theory,  which  led  the  medical  world  captive  for  a  generation,  like 
the  fallacy  of  Phrenology,  in  which  Broussais  likewise  believed, 
has  vanished  before  the  light  of  more  careful  observation.  And 
this  example  should  warn  the  observer  from  asserting  that  an 
inflammation  exists  when  no  other  evidence  of  it  is  present  than 
that  of  redness. 


18  AFFECTIONS    OF    THE    SCALP. 

Swelling  (tumor)  results  from  the  stasis  or  accumulation  of 
an  unusual  quantity  of  blood  in  the  part,  likewise  from  the 
presence  of  leucocytes  or  white  blood  cells,  which,  through  the 
researches  of  Cohnheira  and  others,  have  been  shown  to  emigrate 
from  the  blood  vessels  into  the  adjoining  tissues  during  the 
inliammatory  act;  and,  lastly,  sliould  the  inflammation  be  pro- 
longed, then  the  swelling  is  further  increased  by  a  development 
of  new  cells  which  spring  from  the  connecti-ve  tissue  and  endo- 
thelial elements  composing  the  i)art.  The  density  or  laxit}'  of 
the  tissue  which  is  inflamed  has  a  direct  influence  on  the 
amount  of  the  swelling.  In  parts  which  are  naturally  lianl  and 
den.se,  the  swelling  is  often  scarcely  perceptible,  but  in  those 
which  are  loose  and  yielding,  the  swelling  is  much  greater. 
Examples  of  the  latter  are  seen  in  the  great  swelling  met  with 
in  the  scrotum,  eyelids,  and  lips  when  these  parts  are  inflamed. 
The  redness  and  swelling  of  parts  tend  to  recede  under  the  action 
of  the  inherent  elasticity  of  the  parts.  Inflammatory  tumefaction 
should  not  be  confounded  with  oedema  or  dropsical  swelling;  in 
the  latter  condition  pressure  readily  displaces  the  accumulated 
fluid. 

Heat  (calor)  was  viewed  as  so  important  an  element  in  inflam- 
mation by  the  early  fathers  in  medicine  that  in  both  the  Latin 
and  Greek  tongues  it  gave  name  to  the  process.  The  heat  and 
redness  of  flame,  and  pain  from  too  near  approach  to  the  latter, 
were  eminently  suggestive  of  inflammation  as  manifested  in 
the  human  body.  Yet  the  improved  methods  of  modern  times 
em{)loyed  to  estimate  heat  in  inflamed  structures  have,  curiously 
enough,  led  to  discordant  results.  John  Hunter,  the  earliest 
student  in  the  field,  was  the  first  to  use  the  thermometer.  In  a 
scrotum  the  seat  of  a  hydrocele,  though  heat  was  created  by 
inflammation,  yet  the  temperature  found  was  less  than  that  of 
the  blood  of  the  body.  Later,  many  others,  and  among  them 
Billroth,  continued  this  investigation,  and  as  long  as  the  heat 
was  measured  b}^  the  thermometer,  the  results  in  the  main 
were  negative.  Subsequently  the  testing  was  done  by  means  of 
thermo-electric  instruments,  first  by  Becquerel  and  Breschet, 
and  afterwards  by  the  Etiglish  pathologist,  John  Simon.  The 
method  used  by  Simon  was  to  solder  an  iron  and  platina  needle 
together  at  one  end  and  to  thrust  their  divergent  shafts  into  the 
part  to  be  examined.  These  needles  were  connected  with  a 
copper  wire  which  encircled  an  astatic  polar  needle  or  galvan- 
ometer.    By  such  an  ingeniously  contrived  thermo-electric  appa- 


'  INFLAMMATION.  19 

ratus  the  degree  of  heat  of  the  part  explored  was  accurately 
measured  by  the  deflection  of  the  needle.  The  discordant  results 
obtained  by  the  thermometer  v/ere  now  rectified,  and  it  was 
clearly  shown  that  the  temperature  of  the  inflamed  parts  is 
greater  than  that  of  the  blood  of  the  body.  Otto  AVeber,  who 
<;arefully  repeated  the  experiments  of  Simon,  obtained  the  follow- 
ino;  results  from  the  examination  of  inflamed  and  non-inflamed 
parts,  as  well  as  of  blood  which  is  entering  and  departing  from 
inflamed  structures: — 

1.  An  inflamed  part  is  warmer  than  the  corresponding  unin- 
flamed  part. 

2.  The  arterial  blood  entering  an  inflamed  part  is  less  warm 
than  the  inflamed  part  itself. 

3.  The  venous  blood  departing  from  an  inflamed  part  is  less 
warm  than  the  inflamed  part,  yet  it  is  warmer  than  the  arterial 
blood  which  is  approaching. 

4.  The  departing  venous  blood  is  warmer  than  the  blood  in 
the  veins  of  the  corresponding  non-inflahied  part  of  the  body. 

Hence,  it  is  demonstrated  that  there  is  heat  produced  in  the 
inflamed  part;  and  the  amount  of  this  is  probably  considerably 
more  than  can  be  accurately  estimated,  since  the  cooler  arterial 
blood  which  is  constantly  entering  the  part  must  reduce  its  tem- 
perature. In  connection  with  the  heat  of  inflamed  structures 
when  at  the  surface,  Gierse  has  determined  that^  heat  is  more 
easily  given  off  than  from  parts  in  normal  state.  This  circum- 
stance makes  the  observer  exaggerate  the  temperature  of  the 
part  which  he  is  examining;  and  when  this  is  combined  with  the 
additional  fact  that  the  patient's  sensation  over-estimates  the  lieat, 
we  have  an  explanation  of  the  unanimity  of  the  old  observers 
that  there  is  an  increase  of  heat. 

The  heat  generated  in  an  inflamed  part  is  constantly  being 
dispersed  through  the  effluent  venous  blood  and  added  to  the 
general  temperature  of  the  body;  and  in  this  way  we  can  account, 
to  some  extent,  for  the  general  rise  of  heat  in  one  whose  body  is 
the  site  of  some  inflammation.  The  locally  inflamed  part  must 
not  be  considered  as  the  entire  source  of  heat  in  inflammatory 
fever;  the  generally  increased  temperature  must  be  accounted 
for  chiefly  as  the  result  of  dead  elements  of  disintegrated  tissue 
entering  the  general  circulation.  And  having  entered  the  blood 
these  functionless  elements  become  the  subjects,  as  well  as  the 
promoters,  of  chemical  change  in  which  heat  is  generated. 

The  three  properties  of  inflammation  which  liave  been  con- 


20  AFFECTIONS   OF    THE   SCALP. 

sidered  are  of  an  objective  nature,  susceptible  of  verification; 
pain  (dolor),  the  next  one  to  be  considered,  is  njore  of  a  subjective 
character,  and  escapes  tiie  usual  tests  of  observation.  The 
instrument,  which  might  be  named  an  odynomorneter,  which  can 
detect  and  measure  pain,  lias  not  been  invented.  But  science  is 
continually  adding  to  our  knowledge  and  extending  our  foresight; 
and  art  is  ever  enlarging  our  power  and  sphere  of  action;*  with 
these  faithful  and  fearless  guides,  it  may  yet  be  possible  to  pene- 
trate the  inmost  recesses  of  life,  and  with  scale  and  indicating 
pendulum,  to  measure  sensation  in  its  various  phases.  And 
until  such  metrical  device  has  been  invented,  there  can  be  no 
quantitative  estimate  of  the  pain  Avhich  is  present  in  an  inflamed 
part.  And,  though  so  intangible  that  it  eludes  the  scrutiny  of  the 
five  senses  of  the  observer,  yet  it  is  manifest  enough  to  the 
unfortunate  subject  of  it,  by  whom  it  is  announced  by  interjec- 
tions or  sounds  recognized  by  any  ear,  for  pain  phrases  itself  in  a 
universal  language  which  needs  not  to  be  learned. 

Pain  is  not  an  unerring  sign  of  inflammation,  since  it  may  be 
present  from  an  abnormal  accumulation  of  blood  in  a  part  which 
is  not  inflamed.  The  degree  of  pain  in  an  inflamed  part  depends 
on  several  conditions;  the  chief  of  these  is  an  ample  supply  of 
sensory  nerves  of  either  the  part  affected,  or  of  the  parts  contigu- 
ous to  the  latter. 

The  immediate  cause  of  pain  lies  in  changes  which  may  be 
induced  in  nerves  by  pressure,  mechanical  lesion,  structural  dis- 
integration, or  cell  growth  either  in  the  nerve  or  its  sheatli.  In 
very  many  cases  the  pain  present  is  due  to  swelling  and  the 
resultant  pressure  on  the  nerves.  An  unyielding  texture  of  the 
affected  structure  intensifies  pain.  As  illustrations  may  be  cited 
the  violent  pain  in  a  whitlow,  in  the  fang  of  a  diseased  tooth, 
and  in  the  case  of  an  inflamed  nerve  traversing  an  unyielding 
osseous  foramen  or  canal. 

By  means  of  propagation  through  reflex  routes  pain  may  be 
felt  quite  beyond  the  primarily  affected  part.  Examples  of  this 
occur  in  the  hand,  in  which  an  affected  filament  of  the  median  or 
ulnar  nerve  may  awaken  pain  in  the  whole  hand  and  arm;  and 
an  affected  branch  of  the  trifacial  nerve  may  awaken  pain  in 
other  parts  of  the  face  which  are  supplied  by  the  nerve.  Inat- 
tention to  this  circumstance  has  led  to  errors  in  diagnosis. 
For  instance,  disease  in  the  kidney  or  bladder  may  be  denoted 


■*Comptes  "Positive  Philosophy,"  article  "Biology. 


INFLAMMATION.  21 

only  by  pain  about  the  external  outlet  of  the  urethra,  and  not 
unfrequently  pain  in  the  knee  (as  yet  ill  explained)  has  diverted 
the  attention  of  the  physician  and  misled  him  in  regard  to  the 
true  seat  of  the  disease  in  the  hip  joint.  And  through  the  inter- 
lacing and  intercommunication  of  the  radical  fibers  of  nerves  in 
their  centers  of  origin,  pain  awakened  in  one  part  of  the  periphery, 
as  on  the  neck  or  arm,  may  be  felt  at  some  distant  point  in  the 
lower  part  of  the  trunk. 

These  examples  of  pain,  which  tax  the  anatomist  to  explain 
them,  find  their  analogue  in  these  cases  in  which  the  pain,  instead 
of  reappearing  as  sensation,  awakens  motion.  Thus  an  inflamed 
cornea  causes  spasmodic  closure  of  the  lids;  inflammation  of  the 
mucous  membrane  of  the  pharynx  and  larynx  awakens  muscular 
movements  of  these  parts;  urethral  inflammation  may  induce 
contraction  of  the  sphincters  of  the  bladder,  and  consequent 
retention  of  urine;  inflammation  of  encephalic  structure  can 
cause  the  muscles  to  contract  which  are  concerned  in  vomiting; 
and  lastly,  an  inflamed  peritoneum  is  primarily  indicated  by 
retching  and  vomiting. 

Antecedent  to  the  appearance  of  pain,  there  may  be  detected 
by  cautious  palpation  increased  sensitiveness  of  the  part  in  which 
the  inflammation  is  developing;  this  condition  sometimes  assists 
in  the  discovery  of  approaching  disease  which  is  deep  seated;  yet 
for  its  detection  there  is  required  a  touch  which  has  become 
erudite  by  much  experience  and  careful  training,  for  if  by  rough 
manipulation  we  rudely  question  the  parts,  the  latter  on  their 
part  may  return  us  a  rude  and  misleading  answer,  for  violent 
pressure  may  awaken  pain  in  parts  where  it  does  not  really  exist. 

Though  pain  is  commonly  a  prominent  feature  of  inflamma- 
tion, yet  it  may  be  absent  in  palsied  parts  which  are  inflamed. 
And  such  inflamed  part  through  strangulation  or  pressure  may 
become  gangrenous  without  the  patient's  knowledge;  as  examples 
of  this,  which  should  awaken  prudent  foresight  on  the  part  of 
the  surgeon,  are  decubital  sloughs  which  occur  through  lesions 
of  the  spinal  cord,  or  from  luxation  or  fracture  of  the  spine. 
And  in  an  inflamed  part,  especially  in  structures  which  are 
oedematous,  the  element  of  pressure  may  be  so  excessive  that  it 
finally  extinguishes  sensation;  and  this,  too,  is  a  timely  warning 
that  death  of  the  part  is  impending. 

Inflammation  is  the  peculiar  prerogative  of  living  tissue; 
whether  these  be  lax  or  dense,  highly  vascular  or  non-vascular, 
abounding  in  or  destitute  of  nerves,  all  living  parts  whatsoever 


22  AFFECTIONS    OF    TlIK    .sCALr. 

may  become  iiillained.  Earliest  youth  and  extreme  old  age  have 
no  iniimiiiity  from  it.  But  many  circumstances,  and  among 
these  ai"e  comj)rised  those  just  enumerated,  niodify  and  stamp  it 
with  s})ecial  characteristics.  For  example,  it  may  bo  so  mild  as 
to  run  its  course  quite  unperceived,  or  it  may  be  so  violent  in  its 
action  that  it  soon  extinguishes  the  life  of  its  subject;  and  between 
these  exist  many  intermediate  varieties.  As  a  general  grouping 
founded  on  these  facts,  we  have  acute,  subacute,  and  chronic  inflam- 
mations. 

If  the  phenomena  which  precede,  accompany,  and  follow  an 
inliainmation,  be  studied  in  their  logical  connection  as  an  artic- 
ulated series  of  actions,  there  will  always  be  found  a  causal 
agency  from  which  the  inflammation  originated,  and  which 
determines  the  grade  and  intensity  as  indicated  by  the  foregoing 
division.  The  old  writers,  Van  Helmoiit  and  Staid,  familiar,  per- 
haps, with  the  elFects  of  a  penetrating  thorn,  named  such  cause  a 
spina,  or  thorn;  the  writers  of  recent  time  name  it  an  irritant;  and 
the  initial  stage  as  that  of  irritation.  This  causal  agency  may  be 
classified  under  the  headings  of  mechanical,  physical,  chemical, 
and  toxic,  the  toxic  being  closely  cognate  to  the  chemical.  Ex- 
amples of  the  mechanical  are  wounds  due  to  violence  from  some 
instrument;  an  instance  of  physical  cause  is  the  burn;  one  from 
chemical  agency  is  that  from  a  concentrated  acid  or  alkali ;  and, 
lastly,  toxic  action  is  represented  by  the  so-called  poison,  which 
acts  probably  in  some  undetermined  chemical  way,  dependent 
probably  on  the  respective  molecular  composition  of  the  agent 
and  the  structure  acted  on. 

In  their  descriptions  of  inflammation,  writers  mention  a  species 
which  they  name  idiopathic;  this  occurs  oftenest  in  works  on 
internal  medicine.  The  term  idiopathic  is  a  Avord  coined  to  veil 
ignorance;  such  ignorance,  however,  were  better  acknowledged 
than  concealed  by  the  subterfuge  of  obscure  verbiage.  Every 
effect  or  result  is  linked  to  some  antecedent  causal  agency.  In 
medicine,  as  in  other  branches  of  knowledge,  words  sometimes 
acquire  too  much  importance  and  become  the  counterfeit  expo- 
nents of  what  are  fancied  to  be  facts.  Thus  paraphrased  an  idio- 
pathic or  causeless  inflammation  cannot  rationally  be  conceived 
of.  The  class  of  idiopathic  diseases  is  constantly  lessening  before 
the  advancing  tide  of  observant  investigation. 

Another  agency  claimed  as  causal  is  ascribed  to  certain  para- 
sites discoverable  only  by  the  microscope;  there  are  many  varie- 
ties of. these  microphytes,  or  microbes,  as  some  name  them;  the 


IXFLAMMATIOX.  23 

one,  however,  which  has  received  the  greatest  credit  as  an  agent 
of  inflammation  is  the  genus  bacterium,  whicli  has  lent  its  name 
to  a  new  section  of  medicine,  viz.,  Bacteriology.  The  work  which 
has  been  done  in  this  field,  and  what  has  been  written  on  the 
subject,  constitute  one  of  tlie  most  brilliant  chapters  in  modern 
medical  science.  Tlie  agent  of  disease  which  had  so  long  eluded 
detection,  now  seems,  in  many  cases,  to  be  discovered.  The  san- 
guine minded  are  sure  of  this;  the  prudent,  with  certain 
reservations,  accept  it;  the  cautious  are  hopeful  that  it  is  so,  and 
before  full  acceptance  of  it,  are  waiting  for  further  confirmation. 
Another  class  of  men,  however,  who  are  valuable  as  aids  in  the 
search  for  truth  in  this,  that  they  earnestly  work  as  irrepressible 
contestants,  are  the  skeptics.  This  class,  whose  minds  find  more 
pleasure  in  contemplating  the  vibrating  scales  of  doubt  than  in 
accepting  established  truths,  is  found  here  on  the  side  of  denial. 
Skepticism  finds  an  ally  in  age,  whose  stereotyped  immutabilitv 
scoff's  at  any  new  thing.  The  writer  has  fully  accepted  this  new 
doctrine.  The  evidences  in  favor  of  its  truthfulness  have  so  accu- 
mulated that  it  can  no  longer  be  rejected,  except  by  those  who, 
Cato-likc,  are  onl}-  happy  when  steering  against  the  opinion  of 
their  fellows.  The  writer  wull  not  attempt  to  explain  how  the 
microbe  awakens  an  imflammation,  nor  will  he  deny  that  instead 
of  being  the  antecedent  it  may  finally  be  demonstrated  to  be  the 
concomitant,  or  even  the  subsequent  of  inflammation;  still  the 
two  entities  are  indissolubly  conhected. 

Pathology  has  traversed  four  stages  of  development.  Among 
the  ancients  it  existed  in  the  most  rudimentary  state.  As  proof 
of  this  may  be  cited  Celsus,  who  was  unfriendly  to  the  examina- 
tion of  the  dead  body.  He  believed  that  the  changes  produced 
by  death  are  such  that  no  true  idea  could  be  learned  from  the 
examination  of  dead  bodies  of  their  real  condition  in  life.  It  was 
only  wuth  A^esalius  that  an  epoch  of  accuracy  began.  Vesalius 
won  for  himself  the  title  of  Reformer  in  Anatomy,  because  he  cor- 
rected the  inaccuracies  of  Galen,  who  is  said  to  have  studied  the 
subject  wholly  from  the  dissection  of  monkeys — a  statement  with 
difficulty  credited  by  any  student  of  Galen.  Accurate  knowledge 
of  the  form,  site,  and  aspect  of  the  parts  composing  the  human 
body  made  it  possible  to  discover  and  discriminate  the  changes 
produced  by  disease ;  and  the  labors  of  Vesalius  completing  this 
work,  mark  the  initial  era  of  Pathology. 

The  second  important  epoch  of  advance  in  this  matter  w^as 
ushered   in  by  Bichat.     Amidst  the  excitement  of  the  French 


24  AFFECTIONS    OF    THE    SCALP. 

Revolution,  "which  gave  the  world  so  much  that  was  good  and 
bad,  this  remarkable  genius  appeared,  and  at  the  early  age  of 
thirty-one  years,  wlien  most  men  have  scarcely  learned  to 
think  maturely,  Bichat  gave  to  the  world  his  wonderful  works  on 
"The  Tissues"  and  on  "Life  and  Death."  His  researches  led  ob- 
servation, which  had  hitherto  only  contemplated  the  rude  macro- 
scopical  aspects  left  by  disease  in  the  structures  of  the  dead  body, 
to  a  study  of  the  minuter  changes  and  perversions  whicli  disease 
impresses  on  the  component  tissues.  Bichat's  classification  of  tis- 
sues, though  inaccurate  in  points,  was  a  positive  advance  in 
knowledge,  and  was  the  pioneer  work  in  constructing  the  way  along 
which  others  were  enabled  to  march  to  the  final  site  of  refuge  of 
disease,  which  lies  within  the  sphere  of  the  infinitely  little,* 
which  the  microscope  has  opened  to  us. 

To  this  interesting  field  a  number  of  eminent  investigators 
was  attracted  in  Germany,  France  and  England.  Among  these 
investigators  were  Yirchow,  Henle,  Hasse,  Cornil,  Waller  and 
Wharton  Jones.  The  pathologist  was  engrossed  in  the  study  of 
cell-life,  cell-form  and  cell-change;  for  in  this  field,  really  so 
narrow,  but  which  became  so  broad  under  the  microscope,  lay 
a  great  number  of  treasures  awaiting  disclosure.  The  leader  in 
this  work  was  Rudolf  Virchow,  whose  discoveries  were  so  numer- 
ous and  important  that  they  have  added  a  new  section  to  med- 
icine, viz.,  Cellular  Pathology. 

The  pages  of  this  work  are  *less  poetical  than  those  of  the 
genius  who  wrote  "La  Vie  et  la  Mort,"  yet  those  of  the  former 
constantly  delight  and  instruct,  as  the  writer  depicts  the  eventful 
acts  of  the  cell  in  its  nutritive  and  innutritive  changes,  in  the 
phenomena  of  life  and  death. 

The  tracing  of  the  ever-changing  life  of  the  cell  from  its  birth 
to  its  death,  in  health  and  disease,  has  rendered  equal  service  to 
both  surgery  and  internal  medicine;  in  surgery  it  has  illustrated 
the  inflammatory  processes  awakened  by  the  wound  or  other  irri- 
tant; it  has  revealed  the  initial  conditions  of  Ijoth  benign  and 
malignant  tumors,  placing  those  conditions  under  the  observer's 
eye,  as  it  were,  at  the  very  moment  of  their  conception;  and  finally, 
this  investigation  of  the  cell  has  wrested  from  nutrition  much 
of  its  mystery.  Such  has  been  the  service  which  Virchow  has 
rendered  to  medical  science;  and  as  Bichat  has  been  immortalized 
by  a  prominent  place  among  the  figures  which  emblazon  the 


*P!iscal,  '-Les  Pensecs. 


IXFLA.MMATIOX.  25 

frontispiece  of  the  Pantheon,  so  when  death  closes  the  door  of 
envy,  Virchow  will  liave  perhaps  a  more  conspicuous  place 
among  those  whom  grateful  posterity  will  honor  with  enduring 
remembrance. 

The  fourth,  and  probably  the  final  stage  of  advance  in  the 
search  for  the  factor  of  disease,  is  to  the  concomitant  entity  so 
often  found  associated  with  the  cell,  viz.,  the  microbe  before  men- 
tioned; this  is  now  thought  to  be  the  solving  term  in  the  expla- 
nation of  morbid  action.  Passionate  controversy  on  this  subject 
has  scarcely  yet  arrived  at  the  period  when  a  dispassionate  review 
can  be  made.  The  pioneer  work  in  this  field  of  the  truly 
infinitely  little  was  done  by  Pasteur  in  his  researches  on  fer- 
mentation and  putrefaction.  The  writer  heard  Pasteur  read 
some  of  his  papers  on  these  subjects  at  the  French  Institute  in 
1860,  and  confesses  that  he  foresaw  c[uite  as  little  their  bearing 
on  the  future  of  medicine  and  surgery  as  probably  did  Pasteur 
himself.  These  observations  then  announced  by  Pasteur  were 
the  first  lines  in  the  volume  of '"Bacteriology,"' which  has  since 
been  given  to  the  world;  and  at  this  time  engrosses  so  much 
attention.  The  microphyte  in  its  various  forms  and  diverse  hab- 
itats has  become  the  object  of  study  on  the  part  of  both  ama- 
teurs as  well  as  earnest  students,  and  many  species  have  been 
assigned  special  places  as  Eetiological  agents  of  disease.  And 
what  is  yet  more  important,  the  thing  which  has  been  assigned 
the  part  of  causal  agency,  may,  it  seems  under  certain  manage- 
ment, furnish  immunity  against  the  disease  which  it  originates. 
And  when  this  hope  is  realized,  which  Bacteriology  is  promising 
in  several  directions,  the  accomplished  task  will  remain  a  supreme 
benefaction  to  humanity. 

In  recent  pathological  inA^estigation  there  has  been  a  tendency 
to  overlook  past  methods,  and  to  underrate  past  acquisitions;  the 
bacterium  with  a  special  fascination  has  so  nearly  engrossed  all 
inquiry,  that  the  cell,  the  tissue,  and  the  crude  anatomical  masses, 
have  been  almost  neglected.  This  is  an  error,  and  it  were  well  if 
more  attention  were  given  to  the  appearances  of  parts  revealed 
by  necropsy,  such  as  engrossed  the  attention  of  Morgagni  and 
Hunter,  and  in  the  pursuit  of  which  they  made  many  additions 
to  our  knowledge.  The  knowledge  gathered  by  these  men 
through  work  done  in  the  cheerless  dead-house  is  lasting,  and 
will  bear  comparison  with  the  best  work  done  with  the  micro- 
scope.    And  the  cell  also,  recently  nearly  overlooked,  or  divested 

3 


2G  AFFECTIOXS    OF    THE    SCALP. 

of  inucli  of  its  former  importance,  should  be  porniitted  to  return 
from  partial  exile  to  its  former  place. 

After  this  pathological  excursion,  we  will  resume  the  narrative 
of  inflammation,  and  in  so  doing  will  consider  some  of  its  results. 
The  most  important  of  these  is  the  rai)id  a2)})earance  of  a  number 
of  cell-like  elements.  Some  of  these  elements  have  a  defniite  form 
or  outline;  others  are  irregular  in  shape,  and  some  again  are  dis- 
similar in  size,  and  are  wholly  irregular  in  form.  Those  of  regular 
outline  are  nsually  round,  oval,  or  elongated  in  figure;  the  round 
or  round-like  form  is  the  predominant  one;  deviations  from  this 
are  probably  due  to  pressure.  These  forms  are  only  discernible 
by  the  aid  of  a  microscope,  and,  when  examined  with  this  instru- 
ment, these  cells,  or  corpuscles,  as  the}''  sometimes  are  named, 
are  seen  to  have  one  or  more  dark  points,  named  nuclei,  as  occu- 
pants of  the  cell.  A  })ortion  of  these  corpuscles  are  white  blood 
cells  which  have  forsaken  their  containing  capillaries  b}'  escaping 
through  interstices  in  their  walls.  .Vnother  })(n"tion  originates 
from  preexistent  elements  composing  the  inflamed  tissues.  The 
two  modes  of  origin  here  mentioned  have  been  verified  by  actual 
observjition.  Cohnheim  has  seen  the  white  cells  in  the  act  of 
traversing  the  walls  of  the  minute  vessels  in  their  passage  towards 
the  inflamed  tissue;  and  this  may  be  named  development  by  cell 
immigration.  And  on  the  other  hand  Otto  Weber  and  Billroth 
have  seen  cells  in  different  stages  of  development  arising  from 
inflamed  structures;  and  this  develoj^ment  has  been  named, 
according  to  the  stage  of  growth  in  which  the  corpuscles  are 
observed,  nucleation  and  cellulation,  nucleation  being  the  initial 
period,  while  cellulation  represents  a  more  advanced  stage  of 
development. 

The  cellular  elements  mentioned,  both  the  formless  and  the 
definitely  sha[)en,  are  similar  in  appearance  to  those  which  com- 
pose the  embryonic  being  in  its  early  stages  of  growth,  and  are 
named  by  histologists,  especially  by  Charcot  and  others  of  the 
French  school,  embryonic  elements.  When  such  elements  be- 
come organized,  the  resultant  tissue  in  its  inchoate  stage  is  named 
embryonic  or  granular  tissue.  Charcot  and  Hanvier  have  formu- 
lated as  the  result  of  their  observations  of  the  action  of  inflamma- 
tion that  it  tends  to  reduce  tlie  affected  structure  to  its  primordial 
embryonic  stage.  The  transformation  is  the  same  whether  the 
inflammation  has  attacked  the  organs  of  the  thorax,  abdomen,  or 
surface  of  the  body. 

The  future  destiny  of  these  simple  granular  elements  depends 


inflammation;  events.  27 

on  tlie  grade,  slowness  or  vehemence,  and  special  character  of  the 
inflammation  which  generated  them. 

The  inflammatory  process  may  be  constructive  or  destructive 
in  its  course;  constructive  in  this,  that  lost  structures,  to  a  limited 
extent,  may  he  reproduced  similar  to  the  original  one.  This  is 
true  of  vessels,  nerves,  and,  in  a  slight  degree,  of  muscular  tissue; 
the  new-formed  vessels  seem  to  be  offshoots  from  contiguous 
vessels,  and  the  nerves  appear  to  arise  from  the  extension  of 
preexisting  nerve  filaments.  Again,  the  process  may  be  destruc- 
tive in  its  action,  and  then  the  cellular  and  granular  elements 
remaining  in  their  nascent  or  embryonic  state  die  before  tliey 
reach  the  stage  of  organization;  or,  if  they  reach  organization, 
this  is  of  a  very  rudimentary  character.  Examples  of  destructive 
action  are  seen  in  diptheritis  and  the  rapidly  perishing  products 
of  hospital  gangrene.  The  explanation  of  such  early  death  of 
the  newly-produced  elements  is  that  the  development  of  cells  has 
outstripped  the  growth  of  vessels.  The  cells  die  through  lack  of 
nutritious  material,  and  in  their  death  they  involve  the  underly- 
ing adjacent  capillaries.  In  military  phrase,  the  army  is  lost 
through  leaving  its  commissariat  too  far  behind.  Recent  investi- 
gation makes  it  very  probable  that  certain  forms  of  bacteria  are 
active  adjuvants  in  the  work  of  destruction. 

Through  changes  which  occur  in  the  future  destiny  of  the 
cellular  and  granular  elements  which  have  been  produced  in  the 
inflamed  tissues,  inflammation  may  have  the  following  endings 
or  events: — 

1,  Dispersion  immediate  or  retarded. — In  a  case  of  immediate 
dispersion,  the  inflammation  is  transient  in  duration;  the  redness 
and  swelling  quickly  disappear,  and  the  elemental  products,  few 
in  number,  are  soon  removed  from  the  affected  part.  Or,  instead 
of  being  immediate,  the  dispersion  may  be  retarded  and  take 
place  at  a  somewhat  later  period,  and  in  both  cases  the  inflam- 
mation is  so  completely  innocuous  in  action,  and  the  restoration  to 
normal  type  is  so  entire,  that  hardly  any  vestige  remains  of  what 
has  occurred.  It  should  be  mentioned  that  this  ending  is  known 
also  by  the  name  discussion;  it  is  often  seen  in  slight  wounds, 
and  not  unfrequently  in  larger  ones,  through  the  improved 
methods  which  have  recently  been  introduced  in  the  treatment  of 
wounds.  Certain  anatomical  conditions  favor  such  ending;  for 
example,  an  ample  supply  of  blood-vessels,  and  especially  of  lym- 
phatics, favors  this  rapid  or  immediate  restitution  to  integrity. 


28  AFFECTIONS    OF    TIIR    SCALP. 

2.  Condensation. — Inflammation  may  end  in  condensation  or 
hardening  of  the  alFected  part,  and  this  event  may  present  itself 
in  two  forms,  which  are  the  opposites  of  each  other,  viz.,  enlarge- 
ment, or  hypertrophy,  or  in  diminution,  called  also  atrophy.  In 
the  condition  of  enlargement,  the  swelling  depends  on  increased 
afflux  of  blood  to  the  dilated  capillaries,  and  likewise  on  the 
increased  number  of  cells  and  granules  which  appear  in  an 
inflamed  tissue.  Here  the  conditions  are  such  as  to  offer  an 
obstruction  to  the  escape  of  both  fluid  and  solid  contents.  Con- 
secutive to  such  enlargement,  a  diminution  of  volume  may  occur 
through  escape  of  the  fluid  contents  from  the  part,  and  contrac- 
tion of  the  remaining  solid  elements.  The  actual  state  in  both 
enlargement  and  diminution  is  induration  of  the  structure;  and 
the  induration  is  especially  present  in  the  case  of  atrophic  or 
diminished  volume. 

3.  Adhesion. — Inflammation  has,  as  a  frequent  event,  adhesion 
of  the  affected  structures;  such  adhesion  is  seen  in  the  lessened 
mobility  of  subcutaneous  parts;  thus  muscles  may  become  bound 
together  in  such  a  way  that  their  separate,  individual  movements 
are  interfered  with,  and  consequently,  their  function  is  lost  or 
impaired.  Such  adhesion  may  occur  between  tendons  and  their 
containing  canals,  and  thus  the  movements  of  the  hands  and 
fingers  are  imjiaired  and  hampered.  Vessels  also  may  become 
adherent  to  adjacent  parts,  their  caliber  may  be  diminished,  and 
thus  the  supply  of  blood  to  parts  be  lessened.  Such  adhesion  or 
close  tethering  of  vessels  to  adjacent  structures  near  to  luxated 
joints  favors  atrophy,  and  exposes  the  vessels  to  danger  of  rup- 
ture in  the  work  done  to  reduce  the  luxation,  especially  in  cases  in 
which  reduction  has  long  been  delayed.  Through  adhesion  of  other 
tubular  canals  to  the  parts  inclosing  them,  or  through  coherence  of 
folded  sections  of  their  walls,  their  permeability  may  be  impaired 
through  lessening  of  caliber;  hence  stricture  originates  from  pre- 
vious inflammatory  action.  This  is  seen  in  the  urethra,  in  the 
alimentary  canal,  and  in  other  tube-like  passages.  Adhesion 
arises  in  inflamed  serous  membranes  and  produces  agglutination 
and  fusion  together  of  the  opposite  surfaces;  thus  the  serous  sur- 
face of  the  lung  may  become  attached  to  the  costal  pleura,  and 
the  pleural  cavity  be  partly  or  wholly  obliterated.  The  heart 
may  thus  contract  attachment  to  the  pericardium.  Within  the 
abdomen,  under  the  action  of  peritonitis,  the  serous  surfaces  of 
the  intestinal  coils  may  cohere,  and  the  peristaltic  mobility  of  the 


inflammation;  events.  29 

intestine  be  fatally  interfered  with.  On  the  otlier  hand,  adhesion 
sometimes  becomes  eminently  conservative  in  its  action;  thus  a  per- 
forated bowel  through  adhesion  of  parts  around  has  been  prevented 
from  pouring  its  contents  into  the  abdominal  cavity.  Also,  in  case 
of  abscess  about  the  coecum,  or  in  the  spleen,  or  liver,  through 
adhesion  of  the  wall  of  the  abscess  with  the  abdominal  wall,  a 
way  is  prepared  by  which  the  pus  may  safely  escape  externally. 
I  have  seen  a  gall  bladder  laden  with  many  calculi  thus  get  rid 
of  its  deleterious  burden,  many  months  being  occupied  in  the 
work.  Alongside  of  these  cases  in  which  adhesion  acts  preserv- 
atively,  may  be  cited  a  few  others  in  which  its  result  is  deleterious. 
An  instance  of  this  kind  is  the  palpebral  space,  which,  through 
adhesion  of  the  lid  to  the  globe  of  the  eye,  may  be  almost  oblit- 
erated, and  the  motions  of  the  parts  greatly  obstructed.  Also, 
inflammatory  action  within  the  mouth  can  cause  union  of  the 
cheek  to  the  inferior  maxilla,  so  that  the  action  of  the  jaw  is 
hampered,  and  mastication  rendered  difiicult.  The  phimosed 
prepuce  may  become  adherent  to  the  glans  so  that  the  two  become 
ona  continuous  structure.  Also  in  case  of  burns  in  which  the 
parts  have  been  denuded  of  dermal  integument,  such  parts  readily 
cohere,  if  their  raw  surfaces  remain  in  contact;  the  webbing  of 
fingers  after  a  burn  is  a  familiar  example.  The  art  of  the  sur- 
geon is  severely  taxed  in  preventing  adhesion  in  the  cases 
referred  to,  and  where  it  has  already  occurred,  the  task  is  3^et 
more  difficult  to  restore  the  parts  to  normal  condition. 

4.  Suppuration. — The  event  most  familiar  to  both  the  pro- 
fessional and  the  non-professional  eye,  is  suppuration.  In  this 
eventual  phase  of  inflammation  there  presents  itself  a  remarkable 
product,  technically  called  pus.  The  layman,  from  whose  early 
experience  and  primitive  contact  with  rude  nature  the  nude 
germs  of  all  language  originated,  has  adopted  as  symbol  to  denote 
this  thing  the  most  important  word  in  his  forcible  vocabulary, 
viz.,  matter. 

To  the  unaided  eye,  pus  is  semi-fluid;  it  is  of  a  white  or  yel- 
lowish cream-like  color;  to  the  touch  it  yields  the  slimy  feel  of 
mucus,  and  tested  by  the  sense  of  smell,  its  odor  varies  according 
to  its  source,  or  the  part  of  the  body  in  which  it  has  arisen.  It 
was  deemed  by  Hunter  to  be  a  secretion  from  the  tissues,  and, 
like  a  secretion,  it  is  composed  of  corpuscles  of  varying  form 
floating  in  liquid.  In  this  it  is  analogous  to  milk,  saliva,  mucus, 
and  other  secretions,  for  in  them  one  has  varying  form-elements 


30  AFFECTIONS    OF    TIIK    SCAI.l'. 

suspended  in  a  su[)arablc  fluid.  It  may  l)e  compared  to  an 
imperfect  enuilsion,  in  wliicli  the  suspended  iiuiterials  tend  to 
sink  downwards  wlien  loft  in  repose,  for  if  pus  be  allowed  to 
remain  quiescent  for  a  time,  such  a  ])recipitation  of  the  solid 
elements  does  occur.  The  thickness  of  the  deposited  stratum 
varies  in  different  cases,  and  depends  on  the  nature  of  the  struc- 
tures whence  it  emanates;  also,  the  age  of  the  pus  has  an  influence 
on  its  density.  For  example,  when  the  pus  has  long  been  pent 
up  in  a  cavity  of  which  the  containing  walls  favor  absorption, 
then  the  liquid  contents  will  be  found  to  have  disappeared,  and 
a  solid  cheese-like  content  only  remains.  Instances  of  this  are 
seen  in  the  chronic  abscess,  and  so  complete  is  the  solidification 
sometimes,  that  there  is  only  found  a  fossilized  cretaceous  mass. 
Where  the  containing  w^all  is  unfavorable  to  absorption,  as  in  the 
pleura  that  has  become  dense  and  thickened  through  chronic 
inflammation,  then  the  purulent  content  may  remain  liquid  for 
an  indefinite  period.  Such  pus  in  which  the  corpuscular  elements 
are  in  lessened  amount,  and  tlie  containing  fluid  is  in  excess,  is 
that  derived  from  an  ulcerated  surface  of  long  standing;  the 
product  here  is  closely  allied  to  serum;  it  is  almost  transparent. 
A  similar  pus  is  derived  from  the  chronic  fistula,  from  a  surface 
covered  with  exuberant  granulations,  and  from  an  eye  the  sur- 
faces of  which  are  the  site  of  a  chronic  inflammation.  This 
species  of  pus,  characterized  by  its  barrenness  in  form-elements, 
when  emanating  from  a  mucous  surface,  is  with  difficulty  dis- 
tinguished from  the  normal  mucus  produced  by  the  surface. 
Examples  of  this  are  the  catarrhal  sequelae  which  attend  chronic 
inflammationof  the  various  mucous  membranes,  and  particularly 
that  of  the  urethra.  The  interminable  sero-purulent  discharges 
from  such  affected  surface  often  remain,  despite  tlie  best  efforts 
made  for  their  relief. 

Having  considered  the  qualities  of  pus,  primary  and  acquired, 
w^hicli  unaided  vision  perceives,  we  will  next  consider  what  the 
microscope  reveals. 

If  a  drop  of  recently-formed  pus  be  placed  in  the  field  of  a 
microscope  which  magnifies  five  hundred  times,  it  will  be  seen  to 
consist  of  a  fluid  in  which  form-elements  are  floating.  The  fluid 
portion  nearly  resembles  water.  The  solid  content  consists  of 
bodies  of  varying  figure;  many  have  a  rounded  outline,  and  are 
opaque,  or,  at  least,  they  are  dark  in  a])pearance.  If  water  be 
added,  then  these  bodies  become  more  transparent,  and  the  trans- 
parency is  further  increased,  if  acetic  acid  be  added.     This  clear- 


IXFLAMMATIOX;    EVEXTS.  31 

ing  up  is  due  to  the  reagent  clearing  up  the  granular  content  of 
the  corpuscle,  and  then  one  or  more  nuclei  are  brought  to  view. 
This  body,  which  we  will  name  the  pus-corpuscle,  when  magni- 
fied five  hundred  times  will  be  about  two  lines  in  diameter.  In 
its  appearance  and  behavior  under  the  different  tests  to  which 
the  microscope  subjects  it,  it  is  identical  with  the  white  blood- 
cell.  Besides  these  rounded  bodies  there  are  other  elements  less 
regular  in  form,  indeed,  many  are  shaj^eless. 

The  rounded  corpuscles  when  derived  from  recent  pus  present 
certain  remarkable  phenomena,  which  indicate  that  thev  are 
possessed  of  vitality.  For  example,  in  many,  one  sees  movements 
of  the  molecules  within  the  corpuscles,  also  from  its  surface  one 
sees  that  processes  are  projected  outwards,  and  at  another  point, 
retraction  takes  place.  The  motions  are  such  as  enable  the  cor- 
puscle to  change  its  place,  and  are  the  same  as  those  manifested 
by  the  Amceba,  a  minute  organism  familiar  to  the  naturalist. 
This  faculty  of  motion  enables  the  pus-corpuscle  to  move  from 
one  place  to  another,  and  as  the  normal  tissues  of  the  bodv 
abound  with  numerous  lymph-passages  and  spaces  between  the 
elements  of  connective  tissue,  it  is  easily  conceivable  that  pus 
when  external  may  pass  inwards,  or  when  inclosed,  that  it  may 
penetrate  surrounding  parts. 

The  number  of  pus-corpuscles  present  is  very  variable.  In 
some  specimens  the  containing  serum  greatly  predominates. 
Also  the  number  of  cells  endowed  with  mobility  mav  be  small, 
or  quite  absent;  for  example,  none  are  found  in  pus  which  is  old. 
In  pus  which  is  the  product  of  gangrenous  tissue  few  or  no  regu- 
lar corpuscles  can  be  found,  and  the  elements  which  are  seen 
present  no  movement. 

Besides  pus  of  light  or  yellow  color,  examples  have  been  seen 
in  which  it  was  of  a  blue  color.  This  hue  has  been  referred  to 
the  presence  of  vibriones;  others  again,  claim  that  the  color  is  due 
to  some  compound  of  iron.  Pe'trequin  says  that  it  is  caused  bv 
the  sulphuret  of  iron.  The  writer  has  seen  a  case  in  which  the 
pus  was  of  a  purplish  color  with  a  faint  trace  of  blue.  Such  dis- 
colored pus  (whether  blue  or  purp)lish)  has  no  ill  import  so  far 
as  observed  in  the  writer's  experience;  though  a  lurid  omen  to  the 
patient,  yet  it  does  not  interfere  with  the  healing  of  his  wound. 
It  is  probable  that  it  sometimes  arises  from  a  chemical  change 
in  some  ingredient  in  the  bandage  through  contact  with  pus. 
Other  hues  of  pus  have  been  seen:  black  in  that  derived  from 
bone;  j^ellow  in  the  jaundiced  patient,  and  red  when  it  contains 
hgemetine,  or  an  admixture  of  Idood. 


32  AFFECTIONS    OF    THE   SCALP;     SUPPURATION. 

The  pus-corpuscle  has  the  power  of  incorporating  in  itself 
foreign  material  in  molecular  form,  thus  carmine,  blood,  bile,  and 
other  material  of  a  color  that  can  contrast  with  the  content  of  the 
pus-corpuscle  become  incorporated  with  the  latter.  The  conclu- 
sion arrived  at  from  these  facts  is  that  the  corpuscle  is  not  a  true 
cell,  it  has  no  containing  wall,  its  component  molecules  are  held 
together  by  an  attraction  akin  to  that  which  holds  together  the 
constituent  })arts  of  the  living  body.  The  thoughtful  student  of 
animal  life  and  plant  life  finds  many  examples  of  such  cohesive 
force.  No  more  remarkable  instance  can  be  cited  than  that  of 
the  fixation  of  the  tendon  in  a  bone;  though  seemingly  a  union 
of  the  simplest  order,  yet  the  parts  are  almost  inseparable.  And 
so  an  attractive  affinity  holds  together,  arranged  in  a  spheroidal 
form,  the  constituent  elements  of  the  pus  corpuscle  with  an 
amount  of  force  which  permits  of  motion. 

The  law  of  biological  development  tliat  every  cell  refers  its 
maternity  to  a  preceding  one,  finds  no  exception  in  the  origin  of 
the  pus  corpuscle;  each  one  arises  from  a  kindred  element  in  the 
inflamed  tissues.  As  before  said,  one  of  the  later  acts  of  inflam- 
mation is  the  production  of  a  substance  similar  to  that  constitut- 
ing the  embryo,  and  hence  named  embryonic  tissue.  Nature 
here,  as  in  her  other  acts  which  have  the  purpose  of  continuing 
species,  makes  provision  with  a  liberal  hand;  the  elements  of 
repair  are  furnished  in  excess,  and  those  not  needed  are  cast  off, 
and  in  effluent  fluid  they  are  carried  outside  of  the  organism,  and 
share  the  fate  of  other  excreta.  Or,  dropping  the  figurative  for 
pathological  terms,  pus  is  the  direct  product  of  an  inflamed  tissue; 
the  elemental  forms  contained  in  it  are  the  offspring  of  similar 
elements  in  the  generating  structure,  and  in  an  open  or  closed 
wound,  they  are  nearly  identical  with  those  which  repair  the 
breach.  Every  normal  structure  can  generate  pus,  and  the  same 
law  applies  to  every  abnormal  growth;  carcinoma,  sarcoma,  lipoma, 
fibroma,  chondroma,  etc.,  can  each  produce  a  pus  of  which  the 
elements  correspond  to  those  of  the  maternal  structure.  And  in 
the  case  of  a  tumor  of  which  the  development  is  rapid,  as  in  the 
encephaloid  growth,  if  a  breach  be  made  in  the  surface  of  the 
same,  there  will  be  an  unusually  abundant  production  of  pus. 
Here  the  work  of  organization  does  not  keep  pace  with  that  of 
cell-production,  and  the  unemployed  portion  of  the  latter  appears 
as  purulent  material.  In  the  newly-organized  structure  numer- 
ous fragile  vessels  appear  as  the  predominant  component;  ftom 
these  vessels  emanate  the  fluid  in  which   the  corpuscles  float. 


ULCERATION.  33 

This  fluid  may  very  properly  be  named  serum,  since  it  is  similar 
to  the  serum  of  the  blood. 

Pus,  then,  is  so  nearly  allied  to  the  structure  generating  it 
that  Boerhaave  but  slightly  erred  when  he  named  it  dissolved 
tissue.  In  composition  it  is  nearly  allied  to  blood  which  a  French 
physiologist  has  named  flowing  flesh  (chair  coulante).  Blood  is 
one  of  the  most  costly  products  of  the  animal  organism;  and  the 
near  kindred  of  pus  to  blood  gives  the  former  almost  equal  rank. 
Its  production  on  a  large  scale  is  an  exhausting  drain  on  the 
vital  resources.  The  exhausting  action  from  a  profuse  suppura- 
tion is  nearly  equal  to  that  of  hemorrhage.  An  important  thing 
to  be  borne  in  mind  is,  that  besides  the  loss  to  the  organism 
incurred  through  chronic  suppuration,  it  induces  disease  in  parts 
often  remote  from  the  aff'ected  part;  thus  a  joint  or  bone  the  seat 
of  long-continued  suppuration  causes  renal,  splenic,  hepatic,  or 
intestinal  degeneration  of  amyloid  type;  and  the  life  of  the  sub- 
ject may  thus  be  imperiled  through  innutrition. 

When  pus  is  imprisoned,  or  has  only  imperfect  outlet  for 
escape,  its  elements  undergo  disintegration ;  and  pus  thus  changed 
is  capable  of  being  partly  absorbed;  certainly,  the  pus-serum, 
molecular  elements,  and  bacterial  forms  may  be  absorbed  and 
become  intermingled  with  the  blood.  Virchow  denies  that  pus 
corpuscles  enter  the  body  except  through  open  veins;  the  lessened 
volume  of  retained  pus  clearly  shows  that  partial  absorption  of  it 
is  possible.  And  the  absorbed  purulent  elements  through  chem- 
ical action  cause  fever;  and,  probably,  through  traversing  or 
lodging  in  the  kidneys,  cause  renal  disease.  The  conclusion  here 
come  to  is  justified  by  the  results  of  experiments  made  on  ani- 
mals, in  which  pus  has  been  injected  into  the  blood  vessels. 

5.  Ulceration. — Another  result  of  inflammation  occasionally 
seen  is  ulceration.  This  is  present  in  an  open,  unhealing  wound. 
Similar  conditions  often  exist  in  the  boundary  of  an  abscess, 
which  tends  to  enlarge  rather  than  remain  in  fixed  limits.  It  is 
also  present  in  a  modified  form  in  purulent  infiltration,  where 
pus  disseminates  itself,  and  breaks  down  tissues  contiguous  to  it; 
in  this  instance,  the  inflammation  present  is  of  an  acute  and 
highly  active  character,  but  in  the  others  cited  it  is  of  a  subacute 
or  mild  character.  An  analagous  process  is  seen  in  the  malig- 
nant growth  which  has  opened,  and  whence  pus-like  fluid  is 
eliminated.  Ulceration  on  an  enormous  scale  is  often  present  in 
the  mammary  cancer  in  its  last  stages.     In  the  several  cases  of 


34  AFFECTIONS    OF    THE   SCALP;     ILCKKATIOX. 

ulceration  cited,  there  is  a  slow  breaking  down  of  tissues,  whether 
these  be  normal  or  neoplastic.  And  if  the  conditions  present  be 
studied  and  briefly  defined,  ulceration  is  found  to  be  molccvJar 
structural  disintegration  combined  with  suppuration.  It  occurs  on 
the  skin,  on  the  mucous  membranes,  in  the  serous  surface  of  the 
joints,  in  glands,  muscles,  and  even  in  bones,  in  which  it  is  named 
caries,  the  rule  being  that  structures  which  suppurate  also  read- 
ily become  the  site  of  ulceration.  Ulceration  proceeds  more  rap- 
idly in  lax  parts  than  in  those  which  are  solid  or  hard. 

The  causes  of  ulceration  are  general  and  local. 

The  general  cause,  which  may  also  be  named  predisposirig, 
lies  in  some  peculiarity  or  constitutional  tendency  of  the  subject. 
Scrofula,  tuberculosis,  scorbutus,  and.  syphilis,  each  in  its  way, 
favors  ulceration  in  its  victim,  and  each  modifies  and  gives  an 
imjDress  to  the  ulcer  arising,  so  that  from  an  inspection  of  the 
local  breach  one  gets  diagnostic  proof  of  the  constitutional  tend- 
ency of  the  subject.  There  may  also  be  a  predisposition  less 
general  than  the  cases  just  given;  for  example,  a  diseased  condi- 
tion of  an  artery  through  calcification  of  its  coats,  may  so  impair 
nutrition  in  the  part  to  which  it  is  distributed,  that  ulceration 
on  a  large  scale  may  there  occur.  Illustrations  of  this  liave  been 
seen  in  the  leg,  arm,  and  other  extensive  districts  of  the  body. 
Also,  interruption  of  the  normal  routes  of  circulation  through 
amputation,  furnishes  a  condition  favoring  ulceration  in  the 
stump,  especially,  if  the  latter  is  the  offspring  of  poor  mechanical 
work.  And  cognate  to  the  instances  here  cited  are  those  of  lost 
or  impaired  inneuvation,  as  seen  in  the  palsied  limbs  of  the  hemi- 
plegic  subject  from  fracture  of  the  spinal  cord.  Here  a  slight 
injury,  or  even  continued  pressure,  can  awaken  a  low  form  of 
inflammation  ending  in  ulceration  of  the  affected  parts. 

A  general  predisposition  to  ulceration  exists  in  persons  who 
have  been  the  subjects  of  exposure,  hunger,  and  overwork,  through 
which  the  blood  has  been  impoverished  and  the  strength  of  the 
body  greatly  reduced.  Examples  of  the  kind  the  author  had  an 
opportunity  of  seeing,  some  years  ago,  in  Costa  Kica  among  the 
soldiers  who  had  followed  the  Filibuster  General  AValker,  in  his 
attempted  conquest  of  Nicaragua.  After  his  defeat,  a  number  of 
these  soldiers  were  left  for  a  time  in  the  country  in  great  destitu- 
tion. They  were  emaciated,  anaemic,  bronzed  in  complexion,  and, 
as  prisoners,  living  on  the  smallest  pittance  which  would  sustain 
life.  Many  of  them  had  wounds,  caused  in  most  cases,  not  by 
bullet  or  sabre,  but  by  thorns  which  had  torn  the  skin  in  their 


ULCERATION.  35 

march  through  the  ahiiost  impassable  forests  of  the  tropics.  The 
trailing  vines  which  cling  to  shrub  or  tree  are  armed,  as  a  rule, 
with  sharp  thorns;  a  prick  from  these,  slightly  wounding  the  skin 
of  these  men,  had  caused  ulcers  of  a  remarkable  character.  The 
surface  of  these  was  occupied  b}"  a  pouting  fungoid  substance  of 
a  dirty  yellowish  color;  and  from  this  a  discolored  watery  fluid 
was  exuding.  This  spongy  ulcerating  mass,  often  some  inches  in 
breadth,  rose  considerably  above  the  surrounding  skin.  It  was 
painless,  and  resembled  the  pale  exuberant  masses  which  spring 
from  an  open  encephaloid  tumor.  These  cases  showed  how, 
under  unusual  circumstances,  ulceration  may  deviate  from  its 
usual  course;  in  fact,  the  ulcers  might  easily  have  been  mistaken 
for  malignant  growths. 

Ulceration  can  also  arise  from  local  causes,  many  of  which 
permit  of  a  mechanical  interpretation.  It  may  also  j^roceed  from 
some  irritant  of  chemical  or  animal  origin.  Cases  w-hich  can  be 
explained  mechanically  are  ulcers  in  the  lower  limbs.  The  veins 
here,  during  standing,  are  greatly  swollen,  and  the  blood  in  these 
tubes,  in  accordance  with  the  law  of  hydrostatics,  transmits  its 
weight  to  the  parts  on  and  against  which  it  rests.  And  pressure 
is  increased  by  further  widening  of  the  vessels.  The  continued 
pressure  lowers  nutrition  until  ulceration  commences,  and  the 
ulcer  is  only  healed  by  treatment  adapted  to  lessen  or  counteract 
the  pressure. 

Chemical  agents  which  abstract  w^ater  from  the  tissues,  or 
which  coagulate  their  albuminoid  content,  disturb  the  nutrition 
of  parts  and  may  cause  ulceration.  And  this  property  when  duly 
managed  and  regulated  is  often  utilized  for  curative*  purposes  by 
the  physician  and  surgeon. 

Ulceration  may  be  caused  by  contact  of  some  animal  poison. 
Instances  of  this  are  seen  in  glanders  and  in  the  action  of  ser- 
pents' poison.  And  akin  to  this  are  the  ecthymatous  ulcers 
sometimes  seen  by  the  surgeon  as  the  embarrassing  attendant  on 
some  wound  or  operation,  especially  in  operations  on  the  neck  of 
the  scrofulous  subject.  The  discharge  from  such  ulcers  infects 
the  skin  around,  in  which  appear  minute  vesicular  eruptions, 
which  soon  enlarge,  pass  into  a  purulent  state,  and  then  open, 
and  the  affected  part  remains  as  an  extending  ulcer,  unless 
arrested  by  some  local  remedy. 

Scars,  from  their  low  vital  endowment,  are  disposed  w^hen 
wounded,  or  even  slightly  irritated,  to  inflame  and  ulcerate. 
The  inherent  quality  of  cicatricial  tissue  to  contract,  may  proceed 


36  AFFECTIONS   OF   THE   SCALP;    MORTIFICATION. 

to  such  an  extent  that  from  a  sHglit  cause  a  rupture  of  surface 
occurs  in  it,  which  remains  as  an  unliealing  ulcer;  examples  of 
this  are  seen  in  the  scars  from  large  burns. 

Where  the  skin  rests  on  a  prominent  ridge  or  crest  of  bone, 
and  from  the  absence  of  subjacent  soft  structure  it  is  the  subject 
of  pressure  from  within  and  exposed  to  violence  from  without, 
there  we  have  a  strong  local  predisposition  to  ulceration,  and 
ulcers  occurring  at  such  points  are  very  intractable  to  treatment. 

6.  Mortification. — The  final  and  most  fatal  event  which 
can  proceed  from  inflammation  is  mortification  or  death  of 
the  affected  structure.  Gangrene,  mortification  and  sphacekis, 
names  nearly  synonymous,  are  used  to  designate  dissolution  or 
death  of  tissue.  Tliough  some  writers  attempt  differentiation  of 
the  early,  advanced,  or  ending  stages  of  the  process  by  these  sev- 
eral terras,  yet  their  efforts  to  do  so  seem  only  to  have  obscured 
the  subject.  The  English  and  American  writers,  as  a  rule,  have 
preferred  the  terms  gangrene  and  mortification,  the  latter  having 
precedence;  the  French  writers  use  the  term  gangrene. 

Says  John  Hunter,  "Inflammation  often  produces  mortifica- 
tion or  death  in  the  part  inflamed.  This  commonly  takes  place 
in  old  people  that  are  very  much  debilitated,  and  chiefly  in  the 
lower  extremities."  And  from  Hunter  to  the  present  period 
most  English  and  American  writers,  in  treating  of  inflammation, 
mention  mortification  as  one  of  its  terminations. 

Mortification  presents  itself  in  two  forms,  moist  and  dry.  In 
the  moist  species  the  dead  structure  is  saturated  with  ichorous 
fluid;  this  fluid  consists  of  decomposed  blood  intermingled  with 
the  detritus  of  dead  tissue.  This  humid  form,  as  it  is  sometimes 
named,  is  seen  in  cases  in  which  the  death  of  the  structure  was 
rapid  and  had  been  preceded  by  swelling  and  local  congestion. 
Examples  of  the  moist  form  are  seen  in  carbuncle,  in  the  destruc- 
tive action  of  the  cattle  poison,  in  the  localized  gangrene  which 
sometimes  attacks  the  fingers  and  liand,  in  scrotal  sloughing,  in 
the  gangrenous  form  of  syphilis  and  sloughing  from  erysipelas.  A 
bandage  improperly  applied  has  fatally  strangulated  a  limb  and 
furnished  a  striking  example  of  moist  gangrene.  In  nearly  all 
of  the  cases  cited,  there  is  present  some  inflammatory  action 
through  which  there  have  been  a  profuse  cell  production  and 
exudation  of  fluid  within  the  affected  part;  this  newly  introduced 
material,  by  pressure  on  the  vessels,  interrupts  circulation,  when 
death  soon  ensues.  Nutrition  is  prevented  by  excess  of  plastic  or 
building  material.     The  parts  die  surfeited  by  materials,  which 


MORTIFICATION.  37 

under  more  favorable  conditions  might  have  been  valuable  ele- 
ments of  repair. 

The  dry  form,  as  Hunter  says,  occurs  in  the  old  and  feeble, 
and  especially  in  those  in  whom  the  arteries  are  diseased  through 
atheroma  or  calcification;  and  hence  the  parts  supplied  by  them 
are  imperfectly  nourished.  From  its  occurring  chiefly  in  the 
aged,  this  species  is  named  senile  gangrene;  and  in  the  old  it 
often  commences  from  a  slight  injury  of  a  toe.  Contiguous  to 
the  part  in  which  the  mortification  has  begun,  there  will  be 
found  an  abnormal  condition  of  the  structures;  they  are  swollen, 
painful,  and  of  a  dusky  red  color.  And  this  unusual  condition 
seems  to  be  an  accompaniment  of  the  advancing  mortification, 
and  in  reality,  to  be  the  result  of  it.  The  district  of  dead  struc- 
ture awakens  a  low  grade  of  inflammation  in  the  parts  adjoining, 
so  that  the  gangrene  is  both  cause  and  result  of  the  inflammation. 
Certain  French  writers  claim  that  the  arteries  being  inflamed  are 
the  cause  of  senile  gangrene. 

In  parts  of  Europe  where  rye  is  used  as  an  article  of  food, 
and  where  formerly  care  was  not  taken  to  isolate  spurred  rye 
(ergot)  from  the  sound  grain,  the  rye  flour  thus  adulterated 
caused,  in  persons  of  all  ages,  a  mortification  similar  to  senile 
gangrene.  That  ergot  was  the  morbific  cause  was  proven  by 
experiments  on  animals.  The  picture  of  the  disease  as  left  us  by 
eye-witnesses  is  deplorable;  its  subjects  often  made  pilgrimages 
to  distant  shrines,  where  they  unsuccessfully  sought  relief  for 
their  dying  limbs,  a  relief  which  was  found  later  at  the  shrine  of 
jEsculapius.  Intelligent  medicine  here,  as  in  many  other  cases, 
plucked  the  mystery  from  the  matter,  found  in  food  the  cause  of 
ergotism,  as  this  form  of  mortification  is  called,  and  the  peasant 
was  taught  to  save  his  limbs  by  improving  his  bread. 

There  are  many  cases  of  mortification  which  arise  from 
mechanical  closure  of  the  nutrient  vessels  by  means  of  emboli  or 
plugging  clots.  Instead  of  inflammation,  thrombosis  and  embol- 
ism, as  demonstratively  shown  by  the  studies  of  Virchow,  must 
be  regarded  as  the  causal  agency.  In  this  way  a  small  district, 
or  an  entire  limb,  may,  by  deprivation  of  circulating  blood, 
quickly  die  from  inanition. 

Having  considered  the  several  terminations  of  inflammation, 
viz.,  resolution,  adhesion,  suppuration,  ulceration,  and  mortifica- 
tion, there  remain  to  be  noticed  certain  anomalous  endings  which 
sometimes  follow  inflammation  so  closely  that  they  must  be  con- 
sidered as  products  of  it.     Under  this  head  the  simplest  forms 


38  AFFI'X'TIONS    OF   THK     SCALP;     ERYSIPELAS. 

wiiich  can  be  cited  are  the  fibroid  and  keloid  growths,  whicli  are 
often  merel\"  transfbnned  scars,  the  product  of  a  recent  inflam- 
mation. And  finally  must  be  mentioned  cases  of  carcinoma,  in 
which,  though  the  origin  is  recondite  and  obscure,  still  experience 
fully  justifies  the  conclusion  that  tliere  often  exists  the  relation  of 
cause  and  effect  between  inflammation  and  carcinoma.  Examples 
confirmatory  of  this  statement  are  familiar  to  those  occupied  with 
the  treatment  of  malignant  growths.  It  is  seen  in  the  malignant 
growths  which  arise  in  the  mammary  gland,  the  lip,  the  tongue, 
throat,  and  points  of  the  alimentary  canal,  which  are  the  sites  of 
frequent  irritation  or  slight  inflammatory  action. 

Erysipelas. — After  this  review  of  the  phenomena  of  inflamma- 
Lion,  which  was  necessary  for  a  proper  comprehension  of  what 
follows,  we  return  again  to  our  original  subject,  and  resume  the 
study  of  the  surgical  diseases  of  the  scalp.  A  form  of  inflamma- 
tory action  fre(|uently  seen  here  is  erysipelas,  which  we  will  now 
proceed  to  consider. 

The  name  is  from  the  Greek,  and  respecting  its  origin  the 
etymologists  disagree.  One  class  claims  that  it  is  derived  from 
erueiri,  to  draw,  and  jtelas,  the  skin;  but  a  more  probable  deriva- 
tion is  from  eruthros,  red,  and  pelas,  skin,  literally  meaning  red 
skin.  The  disease  is  mentioned  by  Hippocrates  in  his  book  on 
"Epidemics,"  and  he  seeks  for  the  cause  of  erysipelas  in  some 
state  or  constitution  of  the  air,  viz.,  at  the  beginning  of  spring, 
erysipelas  arises  from  some  accidental  cause  in  very  ordinary 
lesions  and  slight  wounds,  no  matter  where  they  may  be  located, 
and  particularly  in  persons  who  are  above  sixty  years  of  age,  and 
the  wound  is  in  the  head.  In  some  cases  the  disease  arises  when 
treatment  has  been  neglected,  and  in  others  it  appears  during 
some  treatment.  In  the  majority  of  cases,  the  disease  ends  in 
suppuration,  and  the  muscles,  tendons,  and  bones  are  destroyed 
on  a  large  scale.  The  fluid  which  escapes  does  not  resemble  pus, 
but  it  is  an  ichor-like  fluid. 

Celsus  states  that  in  what  the  Greeks  named  erysipelas,  there 
is  "inflammation,  redness,  ulceration,  and  pain."  "And  this, 
which  is  named  erysipelas,  not  only  supervenes  on  a  wound,  but 
it  can  originate  without  a  wound,  and  in  each  case  it  is  very 
dangerous,  especially,  if  it  attack  the  neck  or  head."  Celsus 
associates  it  with  cancer  and  gangrene. 

From  the  statements  of  Hippocrates  and  Celsus,  it  is  clear 
that  the  ancients  had  observed  a  causal  connection  between 
wounds  and  erysipelas.     That  the  connection  was  obscure  and 


ERYSIPELAS.  39 

involved  in  mystery,  is  evident  from  the  circumstance  that,  at  an 
early  period,  the  disease  was  called  sacer  ignis,  or  the  sacred  fire. 
Ceelius  Aurelianus  designated  it  by  this  name  in  his  reference  to 
it  as  an  accompaniment  of  diseases  of  the  throat. 

Though  these  ancient  references  to  erysipelas  are  historically 
interesting,  yet  they  give  us  but  vague  notions  of  the  affection, 
for  in  many  particulars  an  accurate  description  of  it  must  be 
sought  for  in  the  modern  writer. 

By  erysipelas  is  meant  a  disease  which  manifests  itself  by 
general  as  well  as  by  local  symptoms.  The  general  or  constitu- 
tional manifestations  are  the  initial  ones.  The  first  one  is  a 
severe  chill,  in  which  the  muscles  tremble,  the  teeth  chatter,  the 
entire  body  is  irregularly  shaken.  Nausea,  and  finally  vomiting 
of  bilious  matter,  supervene.  The  pulse  is  hastened  and  irregu- 
lar in  action.  The  mouth  is  dry,  the  tongue  is  coated,  and  there 
is  intense  thirst.  There  is  pain  in  the  back,  and  a  feeling  of  gen- 
eral fatigue.  The  temperature  of  the  body  is  elevated  three  or 
four  degrees.  There  is  often  delirium,  usually  of  a  mild  char- 
acter, sometimes  amounting  to  merely  a  mental  clouding.  This 
delirium  is  less  during  the  day  than  at  night,  and  is  oftenest 
present  in  erysipelas  of  the  scalp.  These  general  conditions  con- 
tinue from  three  to  six  hours,  when  a  careful  inspection  of  the 
body  will  discover  in  some  parts  of  the  body  a  larger  or  smaller 
district  of  redness  in  which  coexist  the  additional  characteristics 
of  inflammation,  viz.,  heat,  pain,  and  tumefaction.  The  heat  is 
sensible  to  the  patient  and  the  physician.  The  pain  is  slight, 
still  it  is  always  present,  and  assists  in  the  detection  of  the  dis- 
ease, especially  in  the  scalp,  before  there  are  any  visible  mani- 
festations of  it.  Pain  can  often  be  awakened  by  pressure  on  the 
lymphatic  glands,  beneath  or  contiguous  to  the  affected  part;  and 
thus  pressure  awakening  pain  in  the  glands  enables  the  physician 
to  herald  the  coming  disease.  Redness  is  modified  by  the  nat- 
ural tint  of  the  skin;  where  this  is  very  fair,  the  redness  is  more 
conspicuous,  but  where  the  skin  is  dark,  the  redness  may  be 
nearly  absent.  This  is  the  case  in  the  African  and  other  colored 
races.  And  on  the  scalp  the  dark  pigment  of  the  hair  roots  may 
so  disguise  the  surface  that  the  hue  of  erysipelas  can  scarcely  be 
perceived.  The  swelling  depends  on  the  nature  of  the  tissues; 
where  these  are  loose  or  lax,  the  swelling  is  greater;  this  is  seen 
in  the  scrotum  and  eyelids,  which  swell  enormously  when  the 
site  of  erysipelas.  The  swelling  here  is  of  the  nature  of  oedema, 
and  is  due  to  the  transudation  of  serum  from  the  swollen  vessels. 


40  AFFECTIONS    OF    THE    SCALP;     ERYSIPELAS. 

The  enormous  serous  content  present  renders  the  part  pale,  rather 
than  red. 

Erysipehis  niuy  remain  stationary,  and  then  it  is  named  fixed; 
and  in  tliis  case  the  disease  is  confined  to  a  limited  part  of 
the  body,  and  is  the  most  favoraljle  form  with  which  we  liave  to 
deal.  In  another  form  the  affection  spreads  and  occupies  a  more 
extended  surface,  and  from  this  circumstance  it  is  named  migrat- 
ing. The  affected  part  is  always  somewhat  higher  than  the 
adjacent  sound  surface;  and  the  transition  from  the  higher  to  the 
lower  surface  is  sudden  and  abrupt,  so  that  it  can  readily  be  felt 
by  the  observer,  and  tiiis  bounding  line  or  crest  of  the  advancing 
erysipelas  wave  is  sinuous  or  serpiginous  in  direction.  This  ele- 
vation of  the  affected  parts  may  be  taken  as  a  measure  of  the 
grade  or  intensity  of  the  disease,  for  the  disease  presents  itself  in 
varying  degrees  of  violence  from  tliat  which  is  mild  to  that  which 
is  severe.  Tlie  mildest  grade  is  limited  to  the  superficial  part  of 
the  skin,  being  merely  a  simple  dermatitis;  while  the  more  severe 
form  occupies  the  entire  skin  and  subcutaneous  structures;  in  the 
latter  form  there  is  much  more  swelling  than  in  the  former.  The 
grade  of  violence  is  influenced  by  the  constitutional  characteris- 
tics and  hygienic  surroundings  of  the  patient.  The  author  has 
observed  in  the  otherwise  robust  and  health}''  child,  that  erysipe- 
las, though  migrating,  assumes  the  form  of  a  mild  dermatitis,  in 
which,  after  the  lapse  of  two  or  three  days,  the  general  health  of 
the  patient  is  not  seriously  deranged. 

The  disease  occasionally  runs  a  very  irregular  course.  After 
migrating  over  a  large  surface,  and  the  patient  meanwhile  being 
pleased  with  the  hope  that  he  has  reached  the  end  of  his  disease, 
the  latter  retraces  its  steps,  and  reoccupies  the  surface  of  regions 
over  which  it  has  just  passed.  And  this  reappearance  may  occur 
at  isolated  points,  contemporaneously.  In  these  acts  of  recurrence 
the  disease  is  less  violent  than  its  primary  invasion;  the  pain, 
swelling,  and  redness  are  less.  In  this  recurrent  form  the  disease 
may  last  for  a  number  of  weeks.  In  one  case  seen  by  the  author, 
in  which  the  disease  attacked  the  head,  and  especially  the  region 
about  one  ear,  the  aflfection  lasted  some  months,  recurring,  and 
again  recurring  a  number  of  times.  And  in  the  latter  part  of  the 
course,  the  patient  suffered  so  little  that  he  yielded  with  reluc- 
tance to  hospital  discipline.  In  an  ordinary  case  unmarked  by 
irregularities,  the  disease  runs  its  course  in  a  period  varying  from 
ten  to  fifteen  days;  then  the  concurrent  concomitants  vanish,  the 
redness  fades,  the  epidermis  falls  by  piece-meal,  and  in  parts  cov- 


ERYSIPELAS.  41 

ered  by  hair,  the  latter  falls.  The  epidermal  detaeliment  is  due 
to  a  serous  exudation  in  the  meshes  of  the  true  skin;  and  Volk- 
mann  finds  such  exudation  most  abundant  in  the  lower  stratum 
of  the  cutis.  The  hair  may  not  fall  in  mild  cases,  yet  in  severe 
ones  it  does,  and  this  is  caused,  as  Haight  has  shown,  by  the  exu- 
dation of  serum  between  the  roots  of  the  hair  and  its  containing 
sheath.  Again,  where  the  disease  attains  to  a  high  grade  of 
intensity,  the  exudation  is  so  profuse  that  the  epidermis  is 
uplifted  by  the  fluid  in  a  mariner  resembling  the  action  of  a 
vesicant.  And  in  cases  of  the  greatest  severity,  the  disease  for- 
sakes its  accustomed  bounds,  the  inflammation  then  terminates 
in  extensive  suppuration,  which  may  be  in  isolated  foci;  or  there 
may  be  phlegmonous  destruction,  in  which  there  may  be  struc- 
tural death  on  a  large  scale. 

From  the  earliest  times,  as  already  mentioned,  erysipelas  was 
thought  to  have  a  dual  origin,  viz.,  from  a  wound  often  slight  in 
character,  and  from  some  epidemic  influence  or  peculiar  consti- 
tution of  the  air.  This  notion  of  its  connection  with  some 
peculiar  state  of  the  air,  which  is  held  b}^  many  cotemporaries, 
originated  with  Hippocrates,  who  sought  for  the  origin  of  many 
diseases  from  some  state  of  the  atmosphere.  The  obscurity  in 
which  the  matter  was  veiled  in  the  terms  constitution  and  epi- 
demic influence,  was  not  materially  lessened  by  the  substitution 
of  miasm,  by  which  the  occult  agency  has  been  designated,  espe- 
cially by  the  French  in  modern  times.  But  the  miasmatic  agent, 
hitherto  an  intangible  entity,  has  lately  assumed  more  definite 
shape  in  a  microbe  discovered  and  announced  in  1884-85  by 
Fehleisen,  a  German,  and  which,  it  is  claimed,  is  the  veritable 
cause  of  erysipelas. 

The  parasitic  origin  of  erysipelas  announced  in  Germany,  was 
studied  by  Denuce,  in  Paris,  in  1886.  In  nineteen  cases  of  the 
disease,  Denuce  found  the  erysipelas  coccus  of  Fehleisen  in  the 
diseased  tissue  subjected  to  examination;  and  besides  this  microbe, 
Denuce  found  others  in  two  cases.  From  the  microbe  of  Feh- 
leisen he  made  cultures  with  which  he  inoculated  animals,  viz., 
dogs  and  rabbits,  and  erysipelas  was  developed  in  them.  Denuce 
did  not  try  to  inoculate  in  man,  though  Fehleisen  did  in  seven 
cases,  and  Janicke  did  it  in  one  man.  Where  the  erysipelas  is  phleg- 
monous in  character,  besides  the  coccus  mentioned,  Denuce  found 
the  staphlococcus  aureus.  The  parasitic  origin  of  erysipelas  was 
accepted  by  Verneuil  and  others  in  1885.  Verneuil  thinks  the 
microbe  retains  its  vitality,  even  if  situated  in  the  liair,  ear  pas- 


42  AFFECTIONS    OF    THE    SCALP;     ERYSIPELAS. 

sages,  mucous  membrane  of  the  nose,  throat,  or  that  of  the  bowels. 
And  situated  at  any  of  these  points  it  readily  enters  a  breach  of 
the  surface  and  develojjs  the  disease.  In  this  way,  Verneuil 
explains  the  disposition  to  relapse  and  recurrence  after  subsid- 
ence of  the  disease.  The  microbe  commonly  remains  in  the  tissue, 
where  it  can  be  found  for  three  or  four  days,  3'et  this  period  may 
be  greater  and  reach  even  to  fourteen  days. 

The  parasitic  origin  of  erysipelas  explains  the  ready  transition 
of  the  disease  from  place  to  place,  viz.,  the  passage  of  the  affection 
from  the  skin  to  the  mucous  surfaces,  and  reversely.  Thus  it  has 
been  seen  to  pass  into  the  rectum  and  thence  up  to  the  colon,  and 
also  to  enter  the  urethra  and  travel  to  the  bladder,  and,  finally,  in 
the  puerperal  patient  it  may  attack  the  vagina  and  uterus.  It 
may  pass  from  the  pharynx  to  the  middle  ear,  and  from  the 
external  ear  it  may  migrate  to  the  tympanum  and  there  awaken 
sounds  subjectively.  A  physician  once  thus  affected,  told  me 
that  he  heard  the  "singing  of  a  thousand  grasshoppers."  The 
disease  may  j^ass  from  the  eyelids  to  the  bulb  and  there  attack 
the  cornea  and  iris;  it  may  detach  the  retina  and  induce  atrophy 
of  the  choroid  tunic  and  optic  nerve.  In  the  days  when  .sepsis 
trod  quickly  in  the  footsteps  of  the  surgeon,  I  witnessed  the 
removal  of  a  tumor  from  near  the  eye;  an  erysipelas  supervened, 
which  attacked  the  structures  of  the  adjacent  eye,  and,  in  a  few 
days,  permanently  destroyed  vision. 

Both  Fehleisen  and  Denucd  failed  to  find  the  microbe  in  the 
capillaries,  except  in  those  of  the  lungs  and  kidneys.  The  kid- 
neys eliminate  the  parasites  through  the  urine,  and  these  organs 
may  become  diseased  in  this  way. 

This  history  of  the  .mode  of  migration  of  erysipelas,  or  its 
irregularities  in  progress  and  regress,  in  which  it  marches  and 
counter-marches,  strongly  supports,  even  without  the  aid  of  the 
micro.scope,  the  theory  of  microphytic  origin;  for  the  phenomena 
are  those  which  might  be  caused  by  the  |»urposeless  and  erratic 
movements  of  an  independent  organism. 

Ponfick,  in  his  studies  of  erysipelas  in  1867,  announced  that 
he  found  the  inner  lining  of  the  blood  vessels  affected,  and  from 
this  originate  the  thrombi  and  emboli  found  in  the  vessels. 

Few  physicians  and  still  fewer  surgeons  deny  that  the  causal 
agent  requires  a  wound  or  breach  through  which  it  can  gain 
admission  into  the  human  organism.  Accurate  search  rarely 
fails  to  find  such  a  breach,  though  sometimes  it  may  be  so  minute 
as  to  elude  discovery.     Certain  sites  and  conditions  of  those  sites 


ERYSIPELAS.  43 

favor  erysipelatous  development,  for  example,  it  commences  most 
often  at  the  angle  of  the  mouth,  angle  of  the  nose,  and  angle  of 
the  eye,  also  in  the  hair-covered  scalp.  At  the  corners  of  the 
mouth,  nose,  and  eye,  a  condition  favoring  development  is  that 
at  these  transition  points  from  derm  to  mucous  membrane,  lesion 
from  mechanical  or  chemical  cause  often  occurs,  and  this  may  be 
a  mere  fissure  or  slight  abrasion.  This  is  irritated  and  inflamed 
by  the  decomposing  detritus  from  the  adjacent  outlet.  The  con- 
ditions of  the  scalp,  studded  as  it  is  with  glands  and  hair  roots, 
which  are  the  centers  of  exuberant  organization  and  disorganiza- 
tion, are  qualities  favoring  erysipelas.  The  virulent  microbe 
transplanted  in  any  of  the  parts  mentioned,  finds  ample  field  for 
its  nutrition  and  multiplication. 

Wounds  with  certain  peculiarities  favor  the  evolution  of  ery- 
sipelas; among  sucli  are  wounds  which  have  continued  for  some 
time,  and  which  are  nearly  healed.  After  an  amputation  in 
which  ligatures  are  left  hanging  from  the  wound,  as  was  the 
former  custom,  ery.sipelas  sometimes  appeared  around  the  fistu- 
lous opening.  And  the  same  is  tlie  case  with  the  metallic  suture 
employed  to  secure  union  in  pseudarthrosis,  for  in  the  wound 
around  the  wire,  if  it  be  left  projecting,  the  disease  is  wont  to 
appear  in  the  recurrent  form.  AVounds  made  for  plastic  pur- 
poses when  nearly  healed,  and  the  site  of  slight  suppuration,  may 
become  attacked  with  the  disease.  The  silken  sutures  used  for 
the  closure  of  superficial  wounds,  if  not  removed  early,  often 
become  points  of  erysipelatous  infection.  Any  small  wound, 
whether  from  suture  or  other  traumatic  cause,  especially  on  the 
head  and  face,  which,  while  healing  by  suppuration,  becomes 
covered  by  a  crust  or  scab  impeding  the  exit  of  pus,  is  often  the 
starting  point  of  erysipelas;  and  the  early  detachment  of  the  scab 
and  careful  removal  of  the  pus  will  prevent  the  development. 
And  besides  those  of  traumatic  origin,  any  ulcerating  wound, 
whether  of  tubercular, scrofulous,  syphilitic  or  vaccine  origin,  if  the 
exit  of  pus  be  prevented  by  dried  pus,  or  an  impervious  dressing, 
an  erysipelas  can  easily  arise  there.  And  most  favorable  condi- 
tions for  the  evolution  of  the  disease  exist  in  the  scrofulous,  tuber- 
cular or  syphilitic  subject,  in  whom  dead  bone  is  being  detached, 
and  where  an  existing  outlet  for  the  necrosed  material  is  suddenly 
closed.  This  is  often  seen  in  the  necrosis  of  the  frontal  and  nasal 
bones  in  tertiary  syphilis. 

From  the  several  cases  cited  the  induction  follows  that  erysip- 
elas tends  to  appear  at  some  wounded  point  in  which  an  inflam- 


44  AFFKtTIONS    OF    TlIF    SCAL]';    KIIYSIl'KLAS. 

niatiou  has  not  a  free  outlet  for  its  pui'iileiit  produet;  and  these 
conditions  arc  more  favorahle  in  a  sninU,  than  in  a  hirge  wound, 
since  the  extent  of  tlio  hitter  guarantees  tlie  escape  of  ])us. 

As  a  ruk',  the  diagnosis  of  erysi[)ehis  is  readily  made;  the 
inei})ient  chills,  gastric  derangement,  increase  of  heat,  dry  tongue, 
and  intense  tliirst,  and  redness  commencing  at  some  point  and 
traveling  thence  continuously,  are  unmistakable  marks  by  which 
erysipelas  announces  its  presence.  With  these  there  is  commonly 
associated  some  trivial  lesion,  the  point  of  departure  of  the  dermal 
affection;  exceptionally  the  starting-point  may  be  from  the  border 
of  some  large  open  wound,  in  which  the  escaping  purulent  matter 
drying  prevents  the  escape  of  pus.  The  migratory  tendency  of 
the  redness  distinguishes  it  from  a  counterfeit  form  of  the  disease, 
in  which  redness  due  to  a  subjacent  collection  of  pus  is  stationary, 
and  instead  of  ending  at  an  aln'upt  border,  it  fades  insensibly 
into  the  color  of  the  surrounding  parts.  A  neglect  to  note  these 
characteristicSt  or  ignorance  of  their  significance,  has  led  the 
unwary  practitioner  to  accept  and  treat  a  case  for  genuine  ery- 
sipelas, which  was  merely  a  counterfeit  form  of  the  disease. 

The  prognosis  of  erysipelas  is  favorable:  few  among  the  phy- 
sicians of  the  younger  generation  have  seen  deaths  from  it,  and 
this  arises  from  the  improved  hygienic  conditions  whicli  surround 
the  sick,  whether  rich  or  poor,  learned  or  unlearned,  soldier  or 
civilian.  But  where  the  opposite  conditions  exist,  as  prevailed 
in  the  boasted  past,  in  which  the  j^atient  was  the  subject  of  filth, 
foul  air,  and  vitiated  food,  then  the  disease  assumes  a  graver 
form;  and  instead  of  recovery  with  slight  epidermal  exfoliation, 
the  affected  structures,  particularly  the  subcutaneous  tissues,  are 
destroyed  on  a  large  scale,  and  death  often  occurs  from  p)ya3mia, 
or  general  exhaustion.  And  if  regions  be  compared  as  to  their 
relative  peril  when  the  site  of  erysipelas,  the  danger  is  greatest 
when  the  disease  jienetrates  deeply  into  the  orbit;  also  when  it 
attacks  the  deeper  structures  of  the  throat;  in  such  cases,  despite 
the  best  sanitary  surroundings  and  ablest  treatment,  death  com- 
]nonly  claims  the  victim. 

Trcabuent. — As  erysipelas  is  a  dual  compound  of  general  and 
local  morbid  conditions,  so  the  treatment  must  have  two  objects 
in  view;  and  hence  the  remedies  used  must  embrace  both  general 
and  local  means.  Inasmuch  as  the  local  symptoms  are  more 
conspicuous  than  the  constitutional  manifestations,  so  the  former 
have  absorbed  chief  attention  from  both  writer  and  physician ; 
and  this  has  proved  of  detriment  to  the  patient. 


ERYSIPELAS.  45 

The  strength  or  weakness  of  the  patient  should  he  carefully 
considered,  and  the  treatment  made  to  conform  to  the  conditions 
found.  The  weak  subject  should  be  sustained  by  nourishing 
food,  and  by  tonic  and  stimulant  remedies.  Meats  and  their 
extracts,  wines,  and  alcoholic  stimulants  are  likewise  indicated. 
Where  the  debility  is  extreme,  tea  or  coffee  mingled  with  brandy 
should  be  given.  While  the  nutrition  is  thus  being  admitted 
through  the  upper  portion  of  the  alimentar\^  canal,  the  lower  part 
must  be  relieved  of  its  excremental  accumulations  by  simple 
enemata:  but  in  the  strong,  in  whom  there  is  an  amplitude  or 
excess  of  the  vital  forces,  then  the  treatment  may  be  more  ener- 
getic. 

Some  excellent  surgical  authorities,  as  Gosselin,  in  cases  of 
plethora,  favor  bleeding.  The  author  would  prefer  indirect 
depletion  through  the  great  excremental  routes  of  the  skin, 
kidneys  and  bowels,  through  the  use  of  sudorific,  diuretic,  and 
purgative  agents.  As  purgative.  Dr.  Rush's  combination  of  cal- 
omel and  jalap,  ten  grains  each,  has  no  superior.  And  if  there 
is  nausea  and  much  gastric  disturbance,  an  emetic  of  ipecacuanha 
should  be  administered.  Besides  emptying  the  stomach  of  its 
catarrhal  content,  the  mechanical  action  of  vomiting  has  been 
proven  by  experience  to  combat  the  tendency  to  pysemic  devel- 
opment. To  reduce  the  fever  an  antipyretic  may  be  given;  and 
for  this,  for  two  days  in  succession,  ten  grains  of  quinine  may  be 
given  twice  daily;  this  agent  does  double  duty  as  antipyretic  and 
germicide.  In  tlie  debilitated  subject,  quinine  may  be  seconded 
by  some  form  of  iron, -as  the  chloride  or  acetate,  given  in  mini- 
mum doses.  The  large  doses  sometimes  thoughtlessly  given,  of 
both  iron  and  quinine,  are  a  reckless  perversion  of  medicine;  and 
whether  in  this  or  other  kindred  ailments,  instead  of  opponents, 
they  become  allies  of  disease.  Tliey  are  like  valueless  freight 
taken  aboard  of  a  vessel  already  well  laden,  which  is  on  the  eve 
of  a  hazardous  voyage. 

The  remedies  which,  from  time  to  time,  have  been  heralded 
wit]]  praise  for  the  cure  of  tlie  disease  have  accumulated  to  so 
great  a  list  that  the  inexperienced  beginner  in  medicine  is  certain 
that  nothing  wnll  be  easier  than  to  cure  a  case  of  erysipelas.  But 
to  his  chagrin  he  soon  discovers  that  the  law  in  force,  that  num- 
bers carry  strength,  does  not  hold  true  here ;  and  in  time  he  learns 
that  the  opposite  canon  obtains,  viz.,  the  multitude  of  medicines 
advised  is  a  certain  exponent  of  their  inefficiency  and  uncertainty. 
An  attempt  to  collect  tlie  local  remedies  in  groups  offers  the  fol- 
lowino-  classification : — 


4G  AFFECTIONS    OF    THE    SCALP;     ERYSIPELAS. 

1.  T//O.SC  WJiich  Are  Absoluteb/  Inert. — Among  these  may  be 
mentioned  staivh,  flour,  the  seeds  of  lycoj)odiuiH,  also  the  bland 
ointments,  as  Unguentum  Cetacei,  Ceratum  simplex,  Oleum 
Amygdalae,  Adeps,  and,  lastly,  water.  These  remedies  do  not 
limit  the  extension  of  the  disease,  yet  they  have  considerable 
virtue  in  allaying  the  itching  and  burning  of  the  affected  skin. 
The  desiccating  powders  mentioned  are  of  less  value  than  the 
unguents.  The  hpdropathist  claims  much  for  his  panacea  lo- 
cally used.  The  remedies  of  this  list,  though  inert,  have  the 
virtue  of  being  harmless. 

2.  Agents  Wlikh  Constrict. — As  such  are  collodion  and  the 
properly  adjusted  constricting  bandage.  Collodion  has  been  used 
and  praised  by  Brainard,  Cooper,  and  other  American  surgeons. 
Its  constrictive  power,  when  collodion  is  applied  and  let  dry  on 
the  affected  parts  and  surfaces  bounding  the  latter,  lessens  the 
supply  of  blood  to  the  part,  and  this  combats  the  leading  element 
in  the  inflammation.  This  action  reduces  the  erysipelas  to  a  low 
grade;  and  thus  it  controls,  but  it  does  not  remove,  the  disease. 
In  a  child  the  subject  of  the  disease,  though  collodion  was  applied 
by  the  author  with  watchful  diligence,  still  the  disease  was  only 
ameliorated;  and  it  ])assed  from  the  head  to  the  feet,  and  would 
plainly  have  proceeded  further  had  there  been  room  for  exten- 
sion. The  constricting  bandage,  where  the  parts  admit  of  its  use, 
acts  in  a  similar  and  more  effectual  manner  than  collodion;  but, 
like  collodion,  as  every  practical  surgeon  has  witnessed,  it  lessens 
but  does  not  arrest  the  progress  of  the  disease ;  the  eruption  glides 
onwards  beneath  the  bandage. 

3.  Astrinr/ents. — Under  this  head  may  be  mentioned  alum, 
acetate  of  lead,  and  the  sulphate  and  chloride  of  iron.  These 
medicines  when  dissolved  in  water  and  applied  to  tlie  affected 
parts  represent,  in  a  slight  degree,  the  part  of  mechanical  con- 
stringents,  and  in  their  action,  lessen  the  afflux  of  blood. 
According  to  the  writer's  experience,  if  these  weapons  be  per- 
mitted to  re.st  in  their  armory,  the  patient  will  suffer  no  loss;  for 
they  exercise  no  curative  action  against  erysipelas. 

4.  Disintegrants. — Examples  of  these  are  the  preparations  of 
iodine  and  mercury,  of  which  the  action  is  to  cause  molecular 
solution  of  tlie  animal  tissues.  And  the  property  of  disintegra- 
tion explains  their  beneficial  action  in  other  diseases.  In  the 
medical  niind  hitherto  no  article  of  faith  has  been  more  firm!}- 
rooted  than  that  iodine  is  a  remedy  against  erysipela.s.     But  an 


ERYSIPELAS.  47 

extended  series  of  trials  in  which  iodine  was  tried  and  found  to 
have  no  remedial  agency,  led  the  author  long  ago  to  abandon 
its  use  externally  in  erysipelas.  It  burns,  irritates,  vesicates,  and 
discolors  the  skin;  meantime,  the  disease,  undiminished  by  this 
action,  moves  onwards.  Mercury  applied  in  the  form  of  ointment 
has  no  more  efficacy  than  iodine,  and  brings  along  the  additional 
peril  of  salivating  the  patient.  Hence  the  group  of  disintegrants 
may  well  be  dropped  in  the  treatment  of  erysipelas. 

5.  Escharotics. — Of  these  the  nitrate  of  silver  has  been  much 
used,  applied  in  solution,  or  in  full  strength.  The  immediate 
action  is  to  form  a  superficial  eschar  on  the  skin.  The  observa- 
tion that  such  action  does  not  arrest  the  disease  in  the  least 
degree,  soon  led  to  the  abandonment  of  nitrate  of  silver,  especially 
when  it  was  found  that  the  treatment  entailed  a  discoloration  of 
the  skin  which  lasted  much  longer  than  the  disease. 

6.  Vesication. — Somewhat  akin  to  escharotic  treatment  is  that 
by  cantharidal  vesication.  When  Dupuytren  held  reign  in  the 
surgical  world,  his  advocacy  of  blistering  in  erysipelas,  rendered 
the  method  generally  popular.  Blisters  were  directly  applied  on 
the  affected  parts.  But  experience,  than  which  nothing  aids 
more  in  the  art  of  healing,*  did  not  confirm  what  was  proclaimed 
of  vesication;  and  to-day  the  blister  is  almost  forgotten. 

7.  Scarification. — A  new  mode  of  treatment  was  announced  a 
few  years  ago  by  Schutzenberger  of  Strassburg,  of  a  more  heroic 
character  than  most  of  those  already  mentioned  ;  this  consists  in 
making  slight  scarifications  of  the  affected  surface.  For  this 
purpose  slight  cuts  parallel  to  each  other  are  made  with  inter- 
vening intervals  of  about  a  quarter  of  an  inch.  The  surface  is 
slightly  rubbed  so  as  to  promote  the  escape  of  blood  from  the 
incisions;  and  this  blood  is  to  be  spread  over  the  surface  and  al- 
lowed to  dry  as  a  slightly  protective  film.  In  this  way  the  intro- 
ducer of  this  treatment  claims  that  the  surface  is  covered,  and  the 
inflammation  lessened  by  the  withdrawal  of  blood.  Like  other 
plans  of  treatment,  this  one  seems  to  have  done  more  for  its 
inventor  than  for  any  one  else;  it  has  been  abandoned  except  in 
cases  in  which  the  inflammation  assumes  a  high  grade,  and 
destruction  of  the  parts  is  threatened;  in  such,  impending  gan- 
grene may  be  aA'-erted  by  emptying  the  capillaries  in  which  the 
blood  has  ceased  to  move. 

*  Celsus. 


48  AFFECTIONS    OF    THE    SCALP;    ERYSIPELAS. 

8.  Saperfidal  Germicidal  Treatment. — Agents  for  tliispui[»<)se are 
tur[)entiiie,  alcohol,  carbolic  acid,  and  others  of  the  antiseptic 
list,  which  has  so  increased  during  the  last  few  years.  Turpen- 
tine has  especially  been  praise<l  by  Llicke,  who,  having  niixed  it 
with  oil,  covers  the  surface  with  it.  Trials  of  this  agent  made 
by  the  author  have  not  given  very  satisfactory  results.  Its 
disposition  to  spread  and  diffuse  itself  on  the  surface,  renders  its 
use  difficult  near  the  eye,  ear,  nose,  or  mouth.  But  as  these  agents 
only  penetrate  the  surface  very  superficially,  it  is  evident  that  as 
germicides  they  can  have  but  an  imperfect  action;  to  be  effective 
they  must  be  used  as  described  in  the  following  paragraph: — 

9.  ParencJiymatous  Germicidal  Treatment. — Germicidal  remedies 
injected  into  the  tissues  in  front  of  the  advancing  erysipelas  will 
arrest  its  progress.  This  has  been  verified  by  the  author  in  two 
cases,  in  one  of  which  the  agent  used  was  a  three  per  cent  solution 
of  carbolic  acid,  and  in  the  other  the  compound  tincture  of  iodine 
was  employed.  The  work  was  done  cautiously,  only  a  small 
quantity  of  the  remedies  being  injected.  The  result  obtained 
w^as  that  in  no  case  did  the  disease  travel  through  the  structures 
thus  treated.  Yet  through  the  intermediate  uninjected  portions 
the  disease  iintrammeled  continued  its  normal  course.  From  the 
experience  of  the  writer  he  is  convinced  that  where  the  disease  is 
limited  to  a  small  space,  by  the  injection  of  some  germicidal  agent 
around  it  at  short  distances,  the  disease  might  be  effectually  iso- 
lated and  extinguished.  The  amount  to  be  injected,  for  example, 
of  the  tincture  of  iodine,  should  be  from  one  to  two  drops  of  the 
ordinary  Pravaz  hypodermic  syringe.  If  this  amount  ])e  not 
exceeded,  then  the  injecting  may  be  done  at  numerous  points. 
Thus  done  at  an  early  stage  the  disease  may  be  completely  cir- 
cumvallated  and  caused  to  expire  through  isolation. 

Herewith  is  concluded  an  epitomized  summary  of  the  various 
modes  of  treatment  employed  against  erysipelas.  Nearly  all  of 
them  bring  some  relief  and  ameliorate  the  patient's  condition ; 
but  in  none  is  the  hope  of  a  cure  realized  except  by  the  subder- 
mal  method  last  given.  But  when  the  disease  has  already  full 
mastery  of  the  field  by  having  occupied  a  large  surface,  even  this 
plan  could  not  safely  be  pursued;  then  we  should  select  some 
inert  agent  for  local  use,  such  as  almond  oil,  simple  cerate,  or  a 
desiccating  powder.  Besides  this,  the  general  condition  of  the 
patient  must  be  attentively  considered;  and  according  as  exuber- 
ant strength  or  debility  is  present,  or,  as  the  old  Methodists  would 
put  it,  according  as  constriction  or  laxity  predominates,  so  should 
the  constitutional  medication  be  shapen. 


CI-IAPTER   III. 


WOUNDS    OF    THE    SCALP. 


Wounds  of  the  scalp  next  claim  attention,  but  before  consid- 
ering them  it  is  well  to  study  the  general  characteristics  of 
wounds.  The  wound  gave  birth  to  surgery,  of  which  the  nascent 
field  was  furnished  by  war.  Where  violence  ran  riot,  and  the 
soil  drank  and  became  enriched  with  libations  of  human  blood, 
there  grew  the  seminal  germs  of  surgery  close  beside  the  equally 
precious  ones  of  civil  and  religious  liberty.  The  growth  was 
slow,  very  slow,  like  all  things,  which,  through  inherent  value, 
endure.  The  observation  of  wounds,  and  some  knowledge  of 
their  treatment,  antedate  all  written  re'cord.  Machaon  and 
Podalirius  treated  wounds  before  the  deeds  of  olden  times  were 
sung  in  epic  verse,  and  Homeric  hexameter,  long  before  Hippoc- 
rates, tells  us  that  a  pliysician  is  worth  a  legion  of  common  men. 

The  ancients  assigned  a  place  to  ^Esculapius  among  the 
Olympian  Celestials,  thus  giving  medicine  its  representative  in 
the  divine  hierarchy,  and  this  honor  was  probably  assigned  to 
^Esculapius  on  account  of  his  treatment  of  wounds,  for  it  was 
only  to  these  that  his  sons  above  mentioned  gave  attention. 
Wounds  and  diseases  held  places  widely  asunder  in  the  mind  of 
early  antiquity.  Diseases  were  then  regarded  as  penal  entities, 
sent  by  some  offended  god  on  a  mission  of  vengeance,  and  this 
need  not  lessen  our  estimate  of  the  intellect  of  olden  times  wlien 
we  recall  wliat  absolute  ignorance  then  obtained  in  regard  to  tlie 
cause  and  nature  of  maladies  which  were  intrenched  deep  within 
the  invisible  regions  of  the  body.  Coming  from  the  unknown, 
and  going  to  the  unknown  after  it  had  destroyed,  or  perliaps  left 
no  footprint  on  its  subject,  disease  easily  became  an  object  of  awe 
and  religious  fear,  and  for  relief  it  was  natural  that  the  remedy 
was  sought  in  some  appeasing  sacrifice.  In  this  matter  the  hand 
of  cunning  priesthood  is  too  plainly  discernible. 

The  origin  of  the  wound  was  involved  in  no  such  uncertainty; 
its  causal  agency  was  plainly  apparent,  since  it  could  l)e  traced  to 

(  49  ) 


50  WOUNDS    OF    THE    SCALP. 

mail  himself,  or  to  some  violent  natural  force.  The  division  of 
the  healing  art  into  Surgery  and  Jnternal  Medicine  was  most 
natural,  since  such  division  was  founded  in  the  marked  contrast 
between  the  wound  and  disease,  the  one  telling  its  own  story 
plainly,  while  the  other  concealed  its  story  in  mute  mystery. 
Bleeding  and  gaping,  the  leading  features  of  the  wound,  were 
manifest  and  unmistakable,  and  needed  no  interpreter;  but  inter- 
nal disease,  in  order  to  be  divested  of  its  abstruse  obscurity  and 
to  have  complete  interpretation,  required  all  past  time  and  much 
of  the  future.  Disease  in  its  recondite  complexities  has  challenged 
and  exhausted  the  efforts  of  the  best  intellect;  the  wound  is  known 
and  comprehended  by  the  unthinking  child.  Over  twenty  cen- 
turies has  been  occupied  in  reaching  a  treatment  of  wounds  which 
is  now  nearly  perfect.  The  day  is  yet  remote  when  the  same  will 
be  reached  in  Internal  Medicine. 

John  Hunter,  in  some  i^hilosophic  lines,  seeks  to  present  the 
ditference  between  disease  and  wounds.  His  language,  a  model 
of  clearness  and  directness  when  he  details  his  remarkable  experi- 
ments, becomes  complex  and  obscure  when  he  attempts  to  formu- 
late princi}»les  in  deductive  method;  this  is  apparent  when  he 
sa^'s:  "I  may  observe  tliat  all  alterations  in  the  natural  dis})Osi- 
tions  of  a  body  are  the  result  either  of  injury  or  disease,  and  that 
all  deviations  from  its  natural  actions  arise  from  a  new  disposition 
being  formed.  Injury  is  commonly  simple;  disease  is  more  com- 
plicated. The  dispositions  arising  from  these  are  of  three  kinds; 
the  first  is  the  disposition  of  restoration  in  consequence  of  some 
immediate  mischief,  and  is  the  most  simple.  The  second  is  the 
disposition  arising  from  necessity,  as,  for  instance,  that  which 
produces  the  action  of  thickening  parts,  of  ulceration,  etc.  This 
is  a  little  more  complicated  than  the  former,  as  it  may  arise  both 
from  accident  and  disease,  and  therefore  becomes  a  compound  of 
the  two.  The  third  is  the  disposition  in  consequence  of  disease, 
wdiich  is  more  complicated  than  either,  as  diseases  are  infinite. 
...  A  disease  is  a  wrong  action  of  the  living  parts;  the  restora- 
tion to  health  must  first  consist  in  stopping  the  diseased  disposi- 
tions and  actions,  and  tlien  in  a  retrograde  motion  towards 
health.  .  .  .  The  operations  of  restorations  arise  naturally 
out  of  the  accident  itself,  for  when  there  is  only  a  mechanical 
alteration  in  the  structure,  tlie  stimulus  of  imperfection  taking 
place  immediately,  calls  forth  the  actions  of  restoration.  But 
this  is  contrary  to  what  happens  in  disease,  for  disease  is  a  dispo- 
sition producing  a  wrong  action,  and  it  must  continue  this  wrong 
action  till  the  disposition  is  stopped,  or  wears  itself  out." 


WOUNDS    OF    THE    SCALP.  51 

As  a  distinction  between  the  two,  the  following  is  offered: 
Disease  involves  a  large  part,  or  the  whole  of  the  body;  a  wound  is 
primarily  local,  and  it  may  remain  so,  or  it  can  become  a  starting 
point  for  general  diseased  action.  In  both  the  wound  and  disease 
there  is  a  spontaneous  effort  towards  restoration  to  previous  integ- 
rity; unaided  nature  will  often  accomplish  this  work,  but  that 
desirable  end  is  greatly  insured  by  the  cooperation  of  intelligent 
art.  Nature  here  may  be  compared  to  a  blind  workman,  who 
often  needs  a  hand  to  guide  him.  With  pain  one  often  sees 
in  the  retrospective  history  of  medicine  that  the  guiding  hand 
was  also  blind. 

The  modern  definition  of  a  wound  is  a  solution  of  continuity,  a 
sonorous  pedantic  phrase  to  ears  unaccustomed  to  it,  but  through 
■use  it  has  lost  much  of  that  quality.  Stripped  of  a  part  of  its 
Latin  dress,  with  which  classic  language  has  invested  it,  the 
wound  might  be  more  plainly  defined  to  be  a  breach  of  structure 
caused  by  some  external  violence;  in  a  few  exceptions  the  violence 
may  be  caused  by  muscular  action  within  the  body.  The  wound 
is  open  or  closed  according  as  the  skin  is  ruptured  or  not.  And 
this  condition  of  being  open  or  closed  figures  greatly  in  the  grav- 
ity of  the  wound;  in  fact,  its  future  destiny  depends  on  this  cir- 
cumstance, the  closed  wound  pursuing  a  painless  course  towards 
recovery,  unless,  as  sometimes  occurs,  the  closed  wound  becomes 
changed  to  an  open  one. 

Wounds  may  be  classified  as  incised,  lacerated,  contused, 
punctured,  and  those  caused  by  gunshot  and  other  projected  mis- 
siles. The  burn,  though  not  classified  among  wounds,  is  nearly 
allied  to  them;  for  modern  physics  reckons  heat  to  be  a  form  of 
rapid  motion  in  the  thing  heated. 

Incised  Wounds. — These  are  produced  by  the  blow  or  contact 
of  some  instrument  having  a  sharp  edge;  and  variety  in  wounds 
is  determined  by  the  sharpness  or  bluntness  of  the  cutting  edge. 
If  the  edge  of  a  cutting  instrument  be  examined  microscopically, 
it  will  be  found  to  be  notched  or  serrated;  and  under  a  highly 
magnifying  |)ower,  it  is  very  irregular;  the  edge  of  the  sharpest 
instrument  appears  to  be  unevenly  notched.  Now  if  the  instru- 
ment have  a  fine  edge,  the  margins  of  the  residting  wound  will 
be  sharply  angular;  but  the  margins  are  blunter  and  more  irreg- 
ular, according  to  the  dullness  of  the  instrument.  These  minute 
points,  though  seemingly  unimportant  minutiae,  are  not  so,  since 
they  have  a  practical  bearing  on  the  healing  of  the  wound.  For 
time  is  saved,  pean  lessened,  and  scarring  diminished  in  propor- 


Ol:  WolNDS    OF    TIIK    SCAI.T. 

tion  to  the  sliarpncss  of  the  instrument  making  the  incision. 
And  especially  is  this  the  case  when  the  wound  assumes  the  cleft 
or  flap  form;  for  such  flap  when  only  connected  to  the  rest  of  the 
bod}'  by  a  small  pedicle,  lives  or  dies,  according  to  the  sharp- 
ness or  dullness  of  the  instrument  causing  it.  The  thin,  sharp 
blade,  free  from  foreign  material,  and  moving  rapidly,  inflicts  a 
wound  which,  though  on  a  large  scale,  soon  heals.  Such  an  in- 
strument merely  separates  the  tissues,  and  but  slightly  injures 
their  molecular  integrity.  No  particles  of  structure  destroyed 
at  the  time,  or  afterwards  dying,  are  present  to  interlere  with 
iiinnediate  agglutination.  Milton's  fertile  fancy  had  a  concei»- 
tion  of  such  traumatic  characteristics  in  wounds  in  these  given 
and  received  by  the  combatants  in  the  celestial  battle  which  he 
has  depicted. 

The  instrument  of  dull  edge  lacerates;  and  besides,  fatally 
injuring  some  elements,  it  displaces  others,  so  that  exact  coapta- 
tion of  corresponding  parts  is  impossible.  But  in  cases  in  which 
the  wound  has  smooth  surfaces,  kindred  or  similar  elements  can 
again  be  joined,  and  immediate  healing  secured.  By  her  varying 
action  in  these  dilferent  conditions,  nature  gives  an  intelligible 
wink  to  the  surgeon  for  guidance  in  his  cutting  operations;  his 
instruments  should  be  as  sharp  as  sharp  can  be,  and  when' used 
they  should  move  hastingly  and  thoughtfully,  not  rcstingly  and 
loiteringly  in  their  work.  Thus  operating,  the  surgeon  conforms  to 
the  three  rules  of  the  classic  trilogy,  tufo,  cifo  etjucunde;  his  cunning- 
knife  almost  efi'aces  its  own  i^athway,  or  only  insignificant  stig- 
mata remain  to  mark  it  The  cry*  of  the  bistoury  as  it  traverses 
the  scalp  announces  a  dull  instrument  rather  than  unusual  den- 
sity of  structure. 

The  form  and  minute  characteristics  of  wounds  sometimes 
become  the  matters  of  study  in  Forensic  Medicine,  inasmuch  as 
they  have  a  bearing  in  criminal  investigation  in  which  it  is 
sought  to  determine  whether  the  wound  was  self-inflicted,  or  done 
b}'  another's  hand,  or  was  the  result  of  accident.  In  case  of  the 
purely  incised  wound,  its  location  and  direction  will  usually 
determine  whether  it  was  self-inflicted  or  not.  But  in  case  the 
wound  has  irregular  edges,  the  question  sometimes  arises,  By  what 
instrument  was  it  caused?  was  it  a  knife,  club  or  missile?  or  did 
it  originate  in  a  fall  against  a  body  having  a  sharp  projection  or 
cutting  border?  A  solution  of  these  problems  is  frequently  the 
unenviable  task  of  legal  medicine.     Few  eyes  see  and  few  ears 

"  Richet. 


IXCISED    WOUNDS.  53 

hear  all  that  they  might,  through  discipline,  learn  to  see  and 
hear.  But  an  eye  trained  and  skilled  to  detect  exact  outline,  and, 
if  need  be,  aided  by  the  microscope,  will  be  able  to  satisfactorily 
solve  the  problem  here  referred  to. 

The  cardinal  conditions  which  are  present  in  structures  the 
site  of  an  incised  wo'und  are  opening,  bleeding,  and  pain;  as  inflam- 
mation is  sketched  by  four  lines,  named  the  Celsian  quadrangle, 
so  the  gaping  breach,  the  escaping  blood,  and  the  pain  awakened, 
represent  wliat  may  be  named  the  traumatic  triangle.  TJie  sur- 
geon's care  in  tlie  treatment  of  the  incised  wound  is  comprised  in 
attention  to  each  of  these  parts. 

The  opening  is  due  to  lesion  of  muscular  tissue.  Both  striated 
and  non-striated  muscular  structure  contracts  when  it  is  wounded; 
and  Iience,  when  severed,  each  part  retracts  and  leaves  an  inter- 
vening gap.  This  phenomenon  of  retraction  is  doubtless  due 
to  reflex  influence  emanating  from  the  lesion  of  peripheral 
nerves.  The  central  ending  of  nerves  has  been  diligently  studied; 
who  knows  but  that  their  peripheral  terminations  ma}'  have  quite 
as  important  functions?  Besides  this,  it  is  probable  that  the 
containing  tegument  of  the  animal  body  is  normalh/  in  a  state  of 
contracted  tension.  Thus  change  of  volume  of  the  parts  con- 
tained within  is  permitted.  Valentin,  the  Swiss  physiologist,  by  a 
series  of  exj)erinient3  many  years  ago,  determined  this  extensile 
property  of  the  animal  tissues,  and  especially  of  the  skin.  Hyrtl 
has  made  some  similar  ones  with  the  peritoneum,  in  which  the 
resisting  power  and  strength  of  this  membrane  were  tested. 
Farabeuf  in  his  work  on  ligations  and  amputations  has  made 
some  valuable  contributions  on  this  subject.  In  the  mechanical 
calculations  which  should  precede  and  accompany  all  operative 
surgical  work,  the  extensile  and  retractile  property  of  the  parts 
operated  on  must  be  taken  carefully  into  the  account;  ignorance 
or  neglect  of  this  matt-er  is  a  common  cause  of  faulty  result. 
From  inattention  to  the  influence  of  these  inherent  properties  of 
the  animal  structures,  a  beautiful  piece  of  plastic  surgery  has 
often  perished  and  proved  a  bitter  disappointment  to  both  patient 
and  operator.  And  in  no  case  is  neglect  of  the  retractile  property 
of  tissues  attended  with  more  unfortunate  results  tlian  in  the 
work  of  amputation;  thence  can  result  the  painful  and  conical 
stump,  an  ill  requital  for  the  perils  which  the  patient  assumes. 
At  risk  of  life,  a  useless  limb  has  been  exchanged  for  a  useless 
fragment  of  one;  and  all  this  is  due  to  the  fact  that  the  surgeon 
forgot  the  sim23lest  and  most  familiar  fact  of  daily  experience, 


54  WOUNDS    OF    THE    SCALP. 

viz.,  that  the  incised  wound  opens,  its  lips  being  pulled  asunder 
by  tl>e  inherent  retractility  of  tlie  tissues.  And  in  tlie  case  of  the 
ilap  wound,  or  where  the  subjacent  connectin<^  tissue  is  so  loose  as 
to  easily  permit  displacement,  then  the  flap  or  loosened  structure, 
as  experiment  and  observation  have  verified,  retracts  one-third 
its  length.  Retractility  should  also  receive  proper  attention  in 
the  work  of  closing  open  wounds  which  penetrate  deeply.  If  the 
closure  be  merely  superficial,  then  there  will  remain  underneatii 
open  spaces  (dead  room),  in  which  traumatic  excreta  may  be 
imprisoned,  act  as  poison,  and  delay  the  healing. 

The  second  important  result  of  an  incised  wound  is  haemor- 
rhage, Avliich  may  be  slight  or  profuse,  according  to  the  vessels 
wliich  are  wounded.  The  vessels  opened  are  arteries,  veins,  and 
lymphatics.  The  lymph  vessels  require  no  surgical  attention; 
the  arteries  demand  prompt  and  thoughtful  care,  and  so  do  the 
veins  when  those  of  large  caliber  are  wounded.  And  here  the 
character  of  tlie  cutting  instrument  performs  an  important  part; 
the  sharper  the  edge  the  more  profuse  is  the  bleeding,  but  the  dull 
blade  contuses  the  opened  vessels,  and  thus  arrest  of  hsemorrhage 
is  favored,  for  here  partial  torsion  is  caused.  Tlie  jetting  of 
arterial  blood  distinguishes  it  from  the  purling  flow  from  the 
wounded  vein;  the  crimson  blood  from  the  artery  distinguishes 
it  from  the  darker  blood  of  the  vein.  But  where  the  heart  and 
lungs  are  acting  feebly,  these  differences  are  less,  the  arterial 
blood  scarcely  bounds  from  the  wound,  and  from  imperfect  pul- 
monary action  it  is  of  dark  hue.  And  though  in  checking 
bleeding  the  wounded  arteries  should  receive  the  first  attention, 
yet  the  wounded  veins  should  not  be  neglected,  since  the  blood 
escaping  proximally  and  peripherally  from  the  vein  can  equal  that 
escaping  onl}'  proximally  from  the  artery.  The  slow  oozing  of 
venous  blood  may  mislead  as  to  the  quantity  lost.  The  expe- 
rience of  the  practical  surgeon  soon  teaches  him  not  to  neglect 
such  bleeding,  for  the  vein  doing  its  work  at  tortoise  pace,  often 
outstrips  the  leaping  artery  in  fatal  hsemorrhage. 

In  several  parts  of  the  body,  the  direction  of  the  incised 
wound  has  an  important  bearing  on  the  quantity  of  blood  lost. 
As  a  rule,  vessels,  and  it  may  be  added  nerves  too,  lie  in  inter- 
muscular interstices,  and  parallel  to  the  adjacent  muscles.  This 
is  especially  true  in  the  limbs,  in  which  the  course  of  the  muscles 
and  nerves  corresponds  to  the  long  axis  of  the  limbs.  The  most 
of  the  vessels  that  lie  in  the  superficial  structures  of  the  head  and 
neck  lie  in  lines  converging  towards  the  summit.     The  conse- 


INCISED    WOUNDS.  £)0 

quence  of  such  anatomical  disposition  is  that  on  the  limbs  and 
head  transverse  cuts  wound  more  vessels  than  do  longitudinal 
wounds.  By  utilizing  these  facts,  long  incisions  may  be  made  on 
the  limbs,  and  head,  and  neck,  with  but  moderate  loss  of  blood. 
It  is  only  from  the  practice  of  continually  dissecting  that  this 
guiding  knowledge  is  retained;  thus,  £uid  only  thus,  the  scalpel 
becomes  an  intelligent  instrument  and  ceases  to  wander  from  con- 
servative lines. 

The  side  of  the  traumatic  triangle  which  remains  to  be  con- 
sidered is  pain.  This  depends  on  lesion  of  nerves  wliich  lie  in 
the  track  of  the  incising  agent.  The  pain  of  the  wound  is  most 
acute  in  those  parts  which  are  abundantly  supplied  with  nerves. 
Examples  are  the  labial  and  anal  structures,  those  of  the  outlets 
of  the  genito-urinary  organs,  the  integument  of  the  fingers  and 
toes,  the  mucous  membrane  of  the  nose  and  of  the  eyelids,  and 
the  structure  of  the  auditory  meatus.  In  the  parts  enumerated, 
incised  or  other  wounds  are  very  painful,  even  careless  manipu- 
lation in  which  no  lesion  is  produced,  causes  pain.  "Wounds  in 
the  dorsal  region  of  the  trunk  are  less  painful  than  those  of  the 
anterior  surface;  in  fact,  every  surgeon  has  frec|uently  seen  with 
v/hat  stoical  composure  extensive  incised  wounds  on  the  back  are 
borne,  for  example,  such  as  are  made  for  the  removal  of  fatty 
tumors,  in  patients  who  decline  an  ansesthetic.  As  a  rule,  wounds 
of  the  surface  of  the  body  are  more  painful  than  those  made  in 
parts  deep  seated.  In  the  evolution  of  the  animal  body,  nature, 
in  her  conservative  work,  has  placed  pain  as  a  faithful  sentry  at 
every  outpost  of  the  living  organism,  and  where  danger  oftenest 
menaces,  this  sentrj'-,  though  usually  slumbering,  is  easily  awak- 
ened to  duty.  It  has  been  found  that  transverse  wounds  in 
dividing  many  vessels  cause  much  bleeding;  for  like  reason, 
through  the  division  of  many  nerve  filaments,  they  cause  much 
pain.  These  facts  maybe  advantageously  used  in  operating.  In 
the  removal  of  tumors  and  similar  work,  if  the  first  incision  be 
made  on  the  proximal  side  nearest  the  heart,  then  subsequent 
incisions  will  cause  but  slight  hEemorrhage;  thus  proceeding  the 
surgeon  economizes  blood,  and  also  pain,  if  the  patient  be  con- 
scious. 

The  incised  wound,  except  when  made  by  the  surgeon's  knife, 
is  less  often  seen  in  the  scalp  than  in  the  extremities  and  trunk. 
From  the  dense  structure  of  the  scalp  favoring  laceration  with 
abrupt  edges,  a  wound  similar  to  the  incised  one  ma}"  arise  from 
a  fall,  or  blow  of  a  blunt  instrument. 


5()  V\-()rXDS    OF    THE    SCALP. 

Preparatory  t()  the  treatment  of  incised  or  other  wounas  of 
the  sealp,  tlie  usual  custom  (thougli  not  always  necessary)  is  first 
to  remove  the  hair  around,  and  if  this  be  done  by  shaving,  care 
must  afterwards  be  taken  to  wash  oiY  all  fragments  of  hair;  this 
being  done,  attention  must  first  be  directed  to  controlling  the 
hemorrhage.  This  is  accomplished  in  most  cases  by  catching 
and  pinching,  or  by  pinching  and  twisting  the  wounded  vessel. 
Both  arteries  and  veins  are  to  be  treated  in  .this  way,  though  as 
a  rule,  the  Avoundod  veins  here  cease  to  bleed  spontaneously.  It 
is  often  requisite  to  })atiently  repeat  the  com})ressive  pinching. 
Where  torsion  must  be  combined  with  the  pinching,  then  a  slight 
circumscribing  incision  must  be  made  around  the  end  of  the 
vessel  so  that  it  can  be  seized  by  the  twisting  instrument.  The 
common  small  forceps  may  be  used  for  this  work.  Should  this 
modified  torsion  fail  to  arrest  the  bleeding,  then  the  ligature  in 
some  form  must  bo  resorted  to.  The  author  prefers  alcoholized 
silk,  made  by  immersing  strong  silken  thread  in  a  fifty  per  cent 
solution  of  alcohol.  A  few  hours  of  immersion  serves  to  make 
the  silk  free  from  irritating  qualities.  Retention  in  the  diluted 
alcohol  will  preserve  the  thread  aseptic  and  ready  for  immediate 
use.  Immersion  of  the  silk  in  a  five  }»er  cent  solution  of  carbolic 
acid  will  serve  the  same  purpose  as  alcohol,  yet  the  carbolized 
silk  is  more  irritating.  In  the  use  of  the  ligature  in  the  scalp, 
the  peculiar  relation  of  the  artery  to  the  parts  in  wdiich  it  is 
lodged,  must  be  attended  to.  The  vessel  is  so  adherent  to  the 
fibro-adipose  structure,  that  when  severed  it  can  neitlier  contract 
nor  retract,  as  is  its  wonted  act  when  wounded.  In  a  wound  of 
smooth  surface  the  opened  artery  continues  to  bleed  much  longer 
than  a  wounded  vessel  of  similar  calilx-r  elsewhere  would  bleed. 
And  these  anatomical  conditions  render  accurate  ligation  very 
difficult,  and  before  it  can  be  ligated,  the  artery  must  be  made 
accessible.  This  is  done  by  isolating  the  vessel  by  slight  incisions 
made  around  it,  whereupou  the  ligation  can  be  done.  Instead  of 
the  ligature,  Tillaux  prefers  compression  to  arrest  the  bleeding  in 
wounds  of  the  scalp;  this  is  to  be  done  by  means  of  a  properly- 
comi)ressing  bandage.  Doubtless  a  bandage  applied  by  an  expe- 
rienced hand  might  do  the  work,  yet  such  continuous  jiressure 
soon  becomes  irksome  to  the  patient. 

Another  mode  to  check  bleeding,  which  has  often  been  suc- 
cessfully employed  by  the  writer,  is  that  in  which  the  efferent 
vessel  is  tied  in  mass,  or  by  what  is  known  as  percutaneous  cir- 
cumscription.    For  this  purpose  a  well-curved  needle,  armed  with 


INCISED    WOUNDS.  57 

a  strong,  aseptic,  silken  thread,  is  caused  to  traverse  tlie  tissues 
and  pass  underneath  the  vessel;  next,  a  small  compress  formed 
of  folded  paper  is  laid  over  the  vessel,  and  the  circumscribing 
thread  is  next  tied  tightly  on  the  paper  compress.  This  circum- 
scribing ligature  should  be  removed  at  the  end  of  forty- eight 
hours;  if  allowed  to  remain  longer,  it  can  cause  supj)uration. 
The  thread  should  be  removed  with  care  lest  the  included  vessel 
be  disturbed  and  caused  to  bleed.  This  circumscriptive  compres- 
sion is  best  adapted  to  controlling  haemorrhage  in  wounds  of  the 
temporal  artery,  and  here  it  may  be  necessary  to  do  it  on  both 
the  hither  and  distal  sides  of  the  wound.  Besides  these  methods, 
bleeding  may  be  arrested  coincidently  with  the  work  of  closing 
the  wounded  scalp.  To  do  this,  let  the  sutures  so  transfix  the 
lips  of  the  wound  near  the  vessel  that  when  the  sutures  are  tied, 
they  will  compress  and  close  the  wound.  In  no  structure  is  this 
plan  so  readily  followed  as  in  the  scalp,  since  the  arteries  there 
lie  in  the  skin.  Where  the  vessels  are  situated  deeper,  this 
method,  to  be  successful,  requires  deep  sutures,  for  superficial  and 
even  deep  sutures  inaccurately  used  for  this  purpose  would  allow 
the  blood  to  escape  within  the  tissues.  Some  years  ago  there  was 
reported  a  case  of  death  from  this  cause.  In  the  removal  of  an 
angioma  from  the  scalp  of  a  child,  though  the  wound  was 
closed,  yet  hsemorrhage  continued  subcutaneousl}^,  the  blood 
entering  the  loose  space  between  the  scalp  and  the  pericranium, 
and  was  only  arrested  by  the  attachments  of  the  occipito-frontalis 
muscle.  This  can  more  readily  occur  in  the  child's  scalp  than 
in  that  of  the  adult,  since  the  former  is  less  closely  fastened  to 
the  skull. 

The  hsemorrhage  having  been  controlled,  should  there  be  much 
pain,  an  anodyne  may  be  given;  as  a  rule,  this  will  not  be  required, 
yet  should  it  be,  then  morphia  in  doses  from  a  quarter  to  a  third 
of  a  grain  may  be  given  an  adult  every  four  hours  until  the  pain 
is  relieved. 

Before  the  closure  of  the  wound,  this  must  be  carefully 
cleansed;  this  work  is  done  by  irrigating  with  a  continuous 
stream  of  water  which  has  been  boiled.  Another  agent  for  irri- 
gating is  a  solution  of  corrosive  sublimate,  viz.,  one  part  of  the 
salt  to  two  thousand  of  water;  or,  in  the  absence  of  this,  a  twenty -five 
per  cent  solution  of  alcohol  may  be  used:  All  clots  which  loiter- 
ingiy  cling  to  the  wound  should  be  removed. 

The  work  of  cleansing  being  thus  done,  the  wound  is  to  be 
closed,  an d^  this  may  be  effected  by  adhesive  plaster,  suture  or  by 


58  WOUNDS    OF    THE    SCALP. 

tying  the  unshaven  hair  across  tlie  wound.  The  old  method  of 
shaving  olf  the  hair  for  some  distance  around  the  wouncl,  and 
then  approximating  the  lips  by  adhesive  i)laster,  may  be  charac- 
terized as  very  unsurgical,  and  has  become  nearly  obsolete.  The 
re-growing  hair  soon  lifts  the  plaster  so  that  it  stands  bridge-like 
over  the  widening  gap  beneath.  Until  recent  years  the  scalp 
was  intangible  to  the  suture.  For  in  the  teaching  and  practice 
of  fifty  years  ago  the  suture  was  allowed  no  place  in  the  treat- 
ment of  the  wounds  of  the  scalp.  This  doctrine  was  firmly 
planted  in  the  student's  mind  as  a  truism  intended  to  remain 
there  undisturbed  by  question  or  criticism,  and  rightly,  too,  for 
its  violation  was  followed  by  certain  punishment  in  the  form  of 
an  erysipelatous  inflammation,  ^yhich  started  at,  and  proceeded 
from,  the  points  of  suture.  A  disease  was  thus  awakened  which 
in  gravitv  far  outweighed  the  simple  wound  of  the  scalp.  For  in 
the  olden  days  which  antedate  the  antiseptic  reformation,  the 
needle  and  its  following  thread  often  became  instruments  of  viru- 
lent inoculation.  Infecting  elements  abound  in  the  scalp.  It  is 
an  excellent  lurking  place  for  parasites;  the  civilized  man  has 
eliminated  those  visible  to  his  eye,  but  those  of  microscopic 
minuteness  are  not  so  easily  banished,  for  the  epidermal  and 
furfuraceous  elements,  decomposing  sebaceous  matter  and  the 
retained  excreta  of  the  hair  follicles  are  admirable  habitats  for 
morbific  microphytes.  The  suturing  needle  opened  the  way  and 
the  following  thread  drew  and  lodged  these  elements  of  disease 
within  the  canal,  where  they  multiplied.  Some  were  probably 
contained  within  the  meshes  of  the  thread,  so  that  when  the  field 
is  viewed  with  the  light  of  modern  knowledge,  it  is  a  wonder  that 
erysipelas  did  not  develop  in  every  wound  of  the  hair-clad  scalp. 
But  since  Lister  has  taught  surgeons  cleanliness  and  given  them 
germicidal  w^eapons,  the  scalp  tolerates  the  suture  as  well  as  other 
parts.  The  old  rule  may  be  fearlessly  disobeyed,  or  perhaps 
expunged  from  the  surgical  code.  But  in  doing  so,  both  scalp 
and  suture  must  be  freed  from  every  species  of  infecting  material. 
The  best  suture  is  metallic,  wliich  may  be  of  silver  or  of  copper 
which  has  been  heavily  plated  or  gilded.  Copper  wire,  from  its 
strength  and  flexibility,  is  an  excellent  material  for  suture.  This 
wire  should  be  washed  in  dilute  alcohol;  the  sublimated  solution 
is  unsuited,  since  it  will  tarnish  the  wire.  Chloroform  may  be 
used  for  the  disinfection  of  the  suture,  as  the  author  has  verified 
in  his  experience.  A  well-curved  needle  should  be  chosen,  and 
its  flattened  end  not  so  sharp  as  to  cut  the  fingers  which  use  it. 


INCISED    WOUNDS.  59 

The  wire  passed  an  inch  through  the  eye  should  be  squarely  bent 
over  the  head  of  the  needle,  and  so  twisted  as  to  form  a  uniform 
thread.  Thus  arranged,  the  needle  and  wire  can  enter  a  quarter 
of  an  inch  from  the  edge  of  the  wound,  and  pass  through  the 
lower  part  of  the  fibro-adipose  stratum  and  emerge  at  the  same 
distance  from  the  wound  on  the  other  side.  The  wire  may  now 
be  cut  with  ordinary  scissors,  so  that  one  end,  an  inch  long,  will 
remain  on  each  side  of  the  wound.  These  ends  may  next  be 
united  by  twisting,  and  this  twisting  should  be  done,  not  over, 
but  on  one  side  of  the  wound.  The  twisting  may  also  be  done 
before  the  wire  has  been  cut,  and  in  this  way  the  wire  may  be 
used  more  economically.  The  work  of  suturing  should  be  com- 
menced at  one  end  and  proceed  thence  to  the  other.  The  stitches 
should  be  about  three-quarters  of  an  inch  asunder.  And  should 
the  coaptation  be  incomplete  at  any  point,  a  superficial  suture 
may  be  introduced  there.  In  some  cases  it  is  more  convenient  to 
introduce  the  first  stitch  at  the  middle  of  the  wound,  and  to  pro- 
ceed thence  to  each  end.  Where  the  parts  have  been  well 
cleansed,  one  need  not  shave  the  hair;  but  then  care  must  be 
taken  not  to  include  the  hair  in  the  lips  of  the  wound. 

The  projecting  ends  of  the  metallic  sutures  should  be  bent 
down;  and  to  prevent  their  being  entangled  in  the  superjacent 
dressing,  the  author  advises  to  ensheath  the  ends  in  a  piece  of 
drainage  tube  of  small  caliber.  The  closure  being  completed  to 
this  stage,  some  dressing  is  next  to  be  applied.  A  good  one  is 
lint  saturated  with  compound  tincture  of  benzoin,  known  also 
as  Friar's  balsam  in  former  times,  when  the  priest  was  the 
minister  of  both  religion  and  medicine  to  his  people.  By  this 
dressing  the  wound  is  hermetically  occluded  and  excluded  from 
the  air,  with  the  result  that  it  inflames  in  but  a  minimum  degree, 
and  a  union  almost  scarless  is  often  obtained.  At  the  end  of  two 
days  the  metallic  suture  should  be  removed,  and  if  there  be  some 
retractile  tension  of  the  sutured  parts,  the  removal  may  be  post- 
poned a  day  or  two  longer.  In  the  withdrawal  of  the  suture, 
some  care  is  required  not  to  reopen  the  wound.  The  benzoated 
lint  must  first  be  removed,  by  being  uplifted  from  each  side  of 
the  wound,  then  the  end  of  the  wire  being  seized  with  forceps,  it 
is  so  drawn  upon  that  it  can  be  cut  off  in  the  part  which  had 
been  buried;  then  the  divided  suture  is  to  be  loosened  at  its  other 
point  of  emergence,  and  from  this  side,  viz.,  the  one  opposite  to 
where  it  has  been  divided,  traction  is  to  be  made,  and  thus  the 
wire  is  easily  removed.     During  this  work   the   parts   adjacent 


(JO  WOUNDS    OF    THK    SCALl". 

isliould  be  pressed  on  Avitli  the  fingers,  so  as  to  immobilize  these 
l>cirts  and  the  uniting  wound  contained  in  them.  The  union  will 
now  often  be  found  complete;  yet  should  there  be  seen  any  indi- 
cations of  suppuration,  then  vaseline  (petroleum  gelatum)  con- 
taining four  per  cent  of  carbolic  acid,  should  be  used  as  dressing; 
thus  an  outlet  will  be  furnished  for  any  purulent  material.  If 
proper  care  has  been  taken  in  the  work,  in  most  cases  union  will 
be  found  complete  at  the  first  dressing  when  the  sutures  are 
removed,  viz.,  on  the  third  or  fourth  day.  The  site  of  the  wound 
should  afterwards  be  protected  from  violence  or  irregular  move- 
ment for  a  few  days:  otherwise  it  might  be  reopened. 

Besides  closure  by  wire,  the  work  may  also  be  done  with  cat- 
gut suture,  which  has  the  advantage  that  it  vanishes  by  absor])- 
tion,  and  does  not  require  extraction,  as  must  be  done  with  wire; 
yet  absorption  sometimes  occurs  before  firm  union  is  estfiblished, 
and  then  some  gaping  occurs.  Catgut  should  be  u.sed  where 
there  is  no  tension  of  the  parts. 

Another  method  of  closing  wounds  situated  in  the  hairy  scalp 
is  by  means  of  the  hair  itself.  The  advantage  of  this  plan  is  that 
healing  is  accomplished  without  shaving  the  hair,  and  one  avoids 
the  conspicuous  mark  resulting  from  such  shaving.  To  close 
the  wound  in  this  way,  commence  at  one  end  of  it  by  placing  a 
thread  in  or  alongside  of  the  wound,  and  then  isolate  a  lock  of 
hair  on  each  side  and  lay  this  over  the  thread  across  tiie  wound. 
Xext  the  locks  held  accurately  are  included  in  a  half  knot,  each 
lock  is  next  to  be  tlirned  back  towards  its  own  side,  when  the 
two  are  to  be  held  in  place  by  completing  the  knot.  Tlie  work 
is  to  be  continued  by  a  series  of  knotted  loops,  so  as  to  wholh' 
close  the  wound.  The  wound  being  thus  united,  the  part  should 
be  washed  with  undiluted  alcohol,  and  then  covered  with  dry 
lint  or  cotton  wadding.  This  plan  of  closing  wounds  was  prac- 
ticed by  Dr.  Garwood,  formerly  physician  to  the  City  and  County 
Hospital  of  San  Francisco.  The  striking  advantages  of  it  are 
that  no  sutures  are  used,  and  the  tied  liair  may  remain  undis- 
turljed  until  the  healing  of  the  wound  is  wholly  completed; 
and  when  this  has  occurred,  then  the  threads  may  be  cut  and 
removed,  and  scarcely  any  trace  of  the  ju-evious  injury  will  be 
visible. 

Lacerated  Wounds. — Lacerated  wounds  of  the  scalp  are  next  to 
be  considered.  These  injuries  may  originate  in  two  ways:  in  the 
one  case,  they  may  arise  from  blows  from  some  blunt  object;  and 
then,  if  the  causal  instrument  be  but  slightly  blunt,  the  wound 


LACERATED    WOUNDS.  61 

will  resemble  the  incised  wound  before  described.  The  lacerated 
wound  can  arise  in  a  second  way  by  the  subject  falling  with  his 
head  obliquely  against  tlie  ground,  or  some  object  having  a  blunt 
surface.  The  edges  of  this  wound  are  ragged,  uneven,  and  often 
very  irregular.  The  wound  may  run  in  any  direction;  it  may  be 
straight  or  curved,  it  may  consist  of  a  single  breach,  or  have  one 
or  more  branches  running  from  the  main  opening.  Vessels  are 
opened,  yet  in  such  a  way  that,  as  a  rule,  they  bleed  but  slightly; 
for  the  violence  in  severing  the  vessels  closes  the  latter  either 
completely  or  incompletely. 

Lacerated  wounds  present  themselves  in  two  classes;  in  one, 
there  is  no  lateral  detachment;  in  the  other,  there  is  lateral  sepa- 
ration of  the  soft  parts,  on  one  or  both  sides  of  the  wound.  In 
the  second  form  the  separation  may  comprise  the  entire  thick- 
ness of  the  scalp,  the  pericraiuum  being  included;  this  is  rarer 
than  the  other  form,  in  which  the  separation  is  through  the 
stratum  of  iax  tissue  Avhich  has  previously  been  described,  as 
connecting  the  pericranium  to  the  superjacent  structures. 

The  treatment  of  the  lacerated  wound  without  lateral  detach- 
ment, if  the  margins  be  even  and  untorn,  is  similar  to  that  of  the 
incised  wound.  But  if  the  edges  be  torn  and  crushed,  they  must 
be  trimmed  off;  that  is,  the  breach  is  to  be  converted,  as  nearly 
as  possible,  into  the  form  of  the  incised  wound,  when  it  must  be 
treated  similarly  to  the  latter,  by  suture,  or  tying  the  hair  across 
it,  as  above  described. 

The  cleansing  of  these  wounds  prior  to  closing  them,  should 
be  done  with  scrupulous  care,  more  so,  if  possible,  than  in  the 
simply  incised  wound,  since  in  the  origin  of  the  lacerated 
wound  some  foreign  matter  is  liable  to  be  forced  into,  and 
remain  incorporated  in,  the  structures.  After  closure  has  been 
done  by  one  of  the  plans  mentioned,  the  further  dressing  may 
be  done  with  the  compound  tincture  of  benzoin  or  alcohol.  An 
agent  recently  brought  into  use,  and  of  which  the  excellence  has 
been  established  by  much  experience,  is  iodoform.  Iodoform 
tends  to  maintain  the  parts  aseptic;  it  is  used  pure,  in  the  form 
of  a  finely  levigated  powder,  sprinkled  over  the  wound  and  parts 
immediately  contiguous;  the  dressing  is  ended  by  complete 
occlusion  under  cotton  wadding.  Since  the  above  cases,  as  well 
as  all  other  forms  of  lacerated  wounds,  are  unfavorably  consti- 
tuted for  primary  union,  during  healing  they  should  be  watched 
lest  pus  form  and,  being  retained,  lead  to  ill  consequences. 

In  the  second  group  of  lacerated  wounds  there  is  u|)Hfting  of 


62  WOUNDS    OF    THE    SCALP. 

one  or  both  sides  of  the  soft  parts,  and  this  detachment  may 
indude  the  pericranium,  tliough,  as  a  rule,  this  is  left  intact. 
The  pericranium  is  oftener  uplifted  in  the  young  subject,  more 
rarely  in  the  adult  or  old  subject.  The  detachment  may  be 
slight,  or  it  may  be  on  a  most  extensive  scale,  so  as  to  constitute 
a  large  flap.  Such  flap  at  the  time  of  injury  may  be  so  displaced 
as  to  expose  the  subjacent  skull.  The  flap  when  large  bears 
resemblance  to  one-half  of  a  bivalve  shell. 

The  lacerated  wound  of  flat  valve-shape  is  one  of  the  injuries 
of  the  scalp  demanding  serious  attention;  for  careless  or  improper 
treatment  of  it  may  perilously  compromise,  and  even  end  the 
patient's  life.  The  dangers  here  referred  to  are  seldom  directly 
from  the  wound,  but  more  commonly  they  are  secondary  com- 
plications, or  results  of  it. 

The  lacerated  wound  with  detachment  of  the  scalp  may,  as 
just  stated,  be  on  a  large  or  small  scale;  the  detachment  may  be 
so  slight  as  to  demand  no  attention ;  again,  it  may  be  so  large  as 
to  comprise  a  large  portion  of  the  scalp.  Hyrtl  mentions  a  case 
in  which  the  entire  scalp  was  detached  and  left  hanging  by  a 
pedicle.  As  a  rule,  the  anatomical  conditions  are  such  that  there 
exists  no  doubt  about  the  maintenance  of  the  vitality  of  the 
uplifted  part.  The  free  and  abundant  vascular  anastomosis 
within  the  scalp  is  favorable  to  maintenance  of  its  life.  The 
position  of  the  pedicle  or  V)ase  of  the  flap,  and  also  the  breadth  of 
the  same,  have  an  important  bearing  in  this  matter;  a  narrow 
base  of  attachment  is  unfavorable;  also,  when  the  attachment  is 
downwards  the  chances  of  maintaining  vitality  are  most  favor- 
able; but  these  chances  are  less  when  the  foot  stalk  or  base  is 
directed  towards  the  summit  of  the  cranium. 

An  effort  should  always  be  made  to  save  the  flap,  no  matter 
how  narrow  its  pedicle  of  attachment  may  be ;  even  if  it  should 
be  wholly  detached,  the  surgeon  should  endeavor  to  save  the  part, 
provided  the  patient  be  seen  soon  after  the  receipt  of  the  injury. 
In  the  restoration  of  the  separated  part  to  its  original  site,  the 
conditions  for  reunion  are  very  favorable,  so  much  so  that  an 
attempt  to  save  the  part  should  be  made,  even  though  a  consid- 
erable time  has  elapsed  since  the  d^etachment. 

The  preliminary  and  principal  work,  in  the  treatment  of  the 
lacerated  fla^)  wound,  is  careful  cleansing  of  the  space  or  cavity 
underneath  it;  and  this  is  best  done  by  irrigation  with  a  dilute 
alcoholic  or  sublimated  solution,  of  the  strength  before  given. 
Continue  this  subcutaneous  cleansing  until  all  blood  clots  and 


WOUNDS    OF    THE    SCALP.  63 

other  foreign  ipiaterials  are  removed.  A  syringe  may  be  used  in 
order  to  carry  the  cleansing  fluid  to  the  bottom  of  the  sinuous 
pockets.  This  work  is  often  hastily  or  imperfecth^  done ;  and,  in 
consequence,  pus  forms  and  prevents  the  reunion  of  the  separated 
parts;  and,  what  is  worse,  it  may,  by  burrowing,  increase  the  detach- 
ment of  the  scalp.  Besides  the  removal  of  the  clots,  any  hanging- 
shreds  which  can  be  found  should  be  removed  by  trimming  or 
twisting  off,  and  if  any  bleeding  follows  this,  arrest  it  by  pinch- 
ing or  torsion. 

The  edges  of  the  wound  are  now  to  be  trimmed ;  and  this 
should  be  so  done  that  the  opposite  faces  can  be  accuratel}^  fitted 
to  each  other,  when  they  are  to  be  united  by  suture  or  tying  of  the 
hair.  In  case  the  scalp  be  detached  to  a  great  extent,  then  the 
parts  after  closure  must  be  carefully  watched,  lest  in  the  blind 
pockets  fluids  may  be  poured  out,  and  by  their  intervention  pre- 
vent union,  or  perhaps  lead  to  suppuration.  Should  this  danger 
menace  at  the  time  of  dressing,  then  one  or  more  drainage  tubes 
should  be  introduced  ;  or  should  signs  of  such  accumulation  pre- 
sent themselves  later,  then  a  counter-opening  should  be  made 
through  the  flap  at  such  point  as  will  insure  the  escape  of  the 
liquid  material.  If,  at  the  time  the  wound  is  dressed,  external 
pressure  be  judiciously  made  by  means  of  a  bandage,  it  would 
tend  to  prevent  such  eff'usion  of  fluid.  If  pus  presents  itself  in 
the  drainage  tubes,  or  it  collect  after  closure,  then  open  and  let 
the  cavity  of  the  wound  be  cleansed  daily  by  syringing  it 
with  an  antiseptic  fluid.  This, work  should  be  done  with  a  flex- 
ible rubber  syringe,  and  the  fluid  thrown  in  as  gently  as  possible. 
And  since  forcible  injection  is  apt  to  separate  the  surfaces  which 
are  uniting,  hence,  as  soon  as  the  fluid  has  been  put  in  motion 
through  the  instrument,  the  latter  should  be  curved  into  the 
shape  of  a  siphon,  when  the  fluid  will  move  by  atmospheric 
pressure,  and  not  in  jets  as  occurs  in  simple  syringing;  and  the 
pressure  in  siphoning  may  be  augmented  by  lifting  the  receiving 
end  of  the  syringe.  This  work  may  be  done  by  means  of  an 
irrigator,  which  may  be  made  by  fixing  a  rubber  tube  to  an 
opening  in  the  vessel  which  contains  the  cleansing  fluid.  The 
common  rubber  syringe  with  which  propulsion  is  done  by  com- 
pressing a  bulb,  may  easily  be  converted  into  a  siphon  or  irrigator. 
Whatever  way  may  be  selected  for  cleansing  the  wound,  the  work 
should  be  continued  until  all  traces  of  pus  disappear.  Neglect 
in  this  matter,  through  which  pus  is  overlooked  and  allowed  to 
be  retained,  sometimes  becomes  the  cause  of  erysipelas ;  thus  not 


G4  WOUNDS    OF    THE    SCALP. 

unfrequently,  the  genuine  or  niigniting  Torni  of  thisatiectioii  has 
arisen,  and  as  a  complieation  has  been  more  serious  than  tlie 
wound  itself,  A  spurious  form  of  the  disease,  simulating  true 
erysipelas,  has  occasionally  been  seen  as  the  result  of  retained  pus. 
This  spurious  affection  is  indicated  by  a  purplish  or  dark  red  hue 
of  the  integument  over  and  around  the  retained  pus.  If  this  pus 
be  early  liberated  by  incising  and  washing  out  the  pocket,  then 
the  surgeon  is  pleased  to  find  that  his  suspicions  of  commencing 
erysipelas  were  erroneous,  since  the  red  flush  soon  vanishes. 

Sometimes  the  flap  remains  attached  to  the  adjacent  scalp  by 
a  very  narrow  pedicle;  in  such  case  one  must  try  to  save  it;  and 
to  do  this,  cleanse  and  trim  off  hanging  shreds,  and  replace  the 
flap  in  its  original  site  and  fix  there  by  sutures.  These  sutures 
should  be  as  few  as  will  suffice  to  retain  the  flap  in  i)lace;  too 
many  will  interfere  with  the  blood  supply  required  to  maintain 
the  flap  alive.  All  tension  and  traction  on  it  must  be  avoided, 
especially  so  where  the  flap  is  scarcely  large  enough  to  fill  the 
breach.  If  an  attempt  be  made  to  fill  the  opening  by  stretching 
the  flap,  such  traction  has  the  effect  of  elongating  and  narrowing 
the  vessels  in  the  pedicle,  and  thus  greatly  lessening  the  passage 
of  blood  through  them  in  accordance  with  the  laws  governing 
the  transmission  of  liquids  through  tubes  of  different  caliber.  For 
example,  if  a  tube  be  doubled  in  length,  the  quantity  of  fluid 
passing  through  it  will  be  diminished  one-half;  and  if  Avith  the 
elongation  the  diameter  be  diminished  one-half,  then  tlie  (piantity 
of  fluid  sA'hich  can  pass  through  it  in  a  given  time  will  be  reduced 
to  one-sixteenth  part  of  that  which  would  pass  through  the  tube 
before  elongation  and  narrowing.  This  oflers  an  explanation  of 
the  tendency  to  slough  in  parts  which  are  subjected  to  traction  in 
the  work  of  closing  wounds;  especially  in  wounds  made  by  the 
surgeon  in  operating.  Severe  lateral  traction  is  often  fatal  to  the 
vitality  of  the  part.  Subjacent  or  eccentric  pressure,  which 
stretches  overlying  structures,  as  well  as  extensive  swelling  from 
any  cause,  may,  in  like  manner,  cause  death  through  elongation 
and  narrowing  of  the  nutrient  vessels. 

In  the  attempt  made  to  revivify  a  flap,  and  thus  to  close  the 
wound  with  it,  the  bandage  and  dressing  should  be  such  as  to 
tiioroughly  ])rotect  it;  and  the  dressing,  which  may  consist  of  lint 
and  iodoform,  should  not  be  disturbed  for  two  or  three  days;  the 
sutures  also  should  not  be  removed  for  a  much  longer  time;  and 
on  the  removal  of  the  sutures,  when  wire  has  been  used,  it  should 
be  done  with  care  so  as  not  to  loo.sen  the  flap.     It  often  happens 


CONTUSION    OF    THE    SCALP.  65 

that  but  a  part  of  the  flap  is  found  alive,  perhaps  islets  here  and 
there;  these  are  valuable  aids  in  closure.  These  living  islets  lie 
in  dead  structure,  which  must  be  permitted  to  loosen  and  detach 
itself.  An  effort  to  prematurely  remove  the  sloughing  tissue 
always  endangers  the  living  points;  and  though  there  be  a  strong 
temj^tation  on  the  surgeon's  part  to  aid  Nature,  yet  as  a  rule  she 
will  do  better  when  left  unassisted;  for  if  these  islets  be  once 
loosened  from  the  subjacent  nutrient  ground,  they  v/ill  perish. 
Even  irrigation  violently  done  may  break  their  attachment. 
Some  two  or  three  weeks'  time  will  be  required  for  the  dead 
structures  to  detach  themselves;  a  few  threads  of  fibrous  tissue, 
owing  to  their  immunity  from  disintegration,  often  maintain  the 
connection  much  longer  than  the  period  here  mentioned.  The 
detachment  of  the  sloughs  will  be  favored  and  perhaps  hastened 
by  moist  warmth.  For  this  purpose  cataplasms  of  ground  flax- 
seed or  bark  of  the  slippery  elm  were  formerly  used.  An 
objection  to  these  agents  is  that  they  soon  ferment,  and  hence 
they  require  frequent  renewal.  Instead  of  these  materials,  soft 
linen  or  cotton  cloth,  wet  in  aseptic  water,  may  be  used,  the  cloths 
being  covered  with  oil  silk.  If  the  water  be  made  alkaline  with 
carbonate  of  soda  or  potash,  the  disintegration  will  proceed  more 
rapidly.  This  depends  on  the  property  which  alkalies  have  of 
dissolving  the  albuminoid  compounds.  After  the  complete 
removal  of  the  sloughs,  the  remaining  wound  should  be  dressed 
with  some  bland  ointment  by  which  the  raw  surface  will  be 
protected.  The  use  of  such  ointment,  though  no  better  than 
water,  entails  less  attention;  it  need  not  be  renewed  so  often. 
For  this  purpose  one  may  select  Unguentum  Cetacei,  which, 
smeared  on  lint,  is  applied  to  the  wound,  and  need  not  be  changed 
oftener  than  twice  a  day.  An  excellent  ointment,  which  the 
writer  has  used,  is  made  by  adding  enough  prepared  chalk  to 
Linimentum  Calcis  to  convert  the  latter  into  an  ointment.  The 
important  quality  of  the  ointment  is  that  it  should  be  unirritat- 
ing.  This  mode  of  dressing  should  be  continued  until  the  healing 
is  completed;  for  this,  some  weeks'  time  is  often  required. 

Contusion  of  the  Scalp. — The  contusion  results  from  a  blow 
with  some  blunt  object;  or  it  may  originate  from  a  fall  in  which 
the  head  strikes  some  blunt  object  or  surface.  Its  causation  is 
similar  to  that  of  the  lacerated  wound.  According  to  the  degree 
of  violence,  so  the  wound  may  vary  from  one  of  trivial  degree  to 
one  of  extreme  severity.  The  striking  characteristic  is  swelling, 
which  occurs  quickly  after  the  receipt  of  the  violence,  and  this 


66  WOUNDS    OF    THE    .SCALP. 

is  due  to  lacerated  vessels.  In  the  contusion,  even  of  mild  grade, 
there  is  a  subcutaneous  breacli  of  the  structures,  the  more  fragile 
tissues  suffering  the  most.  In  this  lesion  the  vessels  are  crushed; 
minute  ones,  and,  in  case  of  greater  violence,  large  veins  and 
arteries,  may  be  opened.  Thence  results  effusion  of  blood  into 
the  adjacent  torn  structures,  causing  swelling.  The  effusion  of 
blood  is  termed  extravasation  or  ecchymosis. 

The  extravasated  blood  may  be  of  ca[)illary,  venous  or  arterial 
origin.  Capillary  extravasation  is  that  occurring  in  the  mildest 
form  of  contusion.  The  effused  blood  then  permeates  the  allccted 
tissues  without  definite  limitation.  The  contused  part  is  some- 
what swollen,  and  to  the  toucli  and  scalpel  it  is  denser  than 
normal  tissue.  The  covering  integument,  at  first  normal,  soon 
becomes  discolored;  this  discoloration,  which  originates  in  the 
breaking  up  of  the  red  cells  and  the  dispersion  of  their  coloring 
matter,  remains  often  after  the  other  phenomena  of  the  contusion 
have  vanished.  This  simple  form  of  contusion  (or  bruise,  in  our 
vernacular)  is  nearly  painless;  there  is  felt  by  the  subject  inerely 
an  unnatural  tightness  and  tension  in  it.  It  requires  but  little 
treatment;  at  the  time  of  the  injury,  pressure  will  arrest  most  of 
the  effusion  of  blood  and  so  prevent  swelling.  But  if  seen  after 
the  contusion  has  reached  its  final  limit  of  swelling,  then  tlie 
recovery  may  be  facilitated  througli  friction  with  some  mildly 
stimulating  liniment,  such  as  soap  liniment  or  diluted  Lini- 
mentum  Ammonite;  still,  if  such  cases  of  inild  contusion  be 
committed  solely  to  the  fostering  hand  of  Nature,  restitution  to 
health  will  occur  nearly  as  soon  as  where  there  has  been  surgical 
intervention. 

As  the  antithesis  of  the  mild  form  is  that  where  the  violence 
has  been  so  great  as  to  lead  to  immediate  or  later  destruction  of 
the  integument  implicated;  here  the  elementary  tissues  have  been 
so  acted  on  by  the  casual  violence  that  their  component  molecules 
are  so  displaced  or  altered  as  to  wholly  lose  their  function;  and 
hence  gangrene  soon  appears  in  the  part.  Such  gangrene  is 
indicated  by  a  livid  discoloration.  The  treatment  in  this  case  is 
to  be  directed  to  tlie  separation  of  the  dead  structure  and,  after- 
wards, to  a  closure  of  the  remaining  breach.  If  it  be  ap})arent 
that  oidy  the  outer  stratum  is  destroyed,  then  the  treatment  will 
consist  in  favoring  the  drying  of  this  part;  for  this  purpose  paint 
it  witli  the  compound  tincture  of  benzoin  or  tincture  of  iodine; 
thus  the  dead  part  is  converted  into  an  occluding  eschar  similar 
to  a  scab,  beneath  which  the  wound   heals.     The  dried  eschar 


CO.NTUSION    OF    THE    SCALP.  67 

should  be  let  remain  in  place  until  it  becomes  loose  and  falls  off. 
But  if  the  destruction  extend  through  the  whole  thickness  of  the 
scalp,  then  this  desiccation  cannot  be  obtained;  tlie  detachment 
of  the  gangrenous  part  must  be  favored  by  moist  warmth;  the 
warm  alkaline  water  before  mentioned  may  be  used  to  accelerate 
the  separation  of  the  slough.  After  the  detachment,  one  of  the 
best  dressings  is  that  of  water  containing  two  per  cent  of  alcohol, 
applied  by  means  of  surgeon's  lint.  The  processes  of  granulation 
and  repair  are  thus  favored.  Repair,  however,  ensues  often  very 
slowly,  due  perhaps,  as  Hunter  says,  to  the  remoteness  of  the  part 
from  the  heart;  the  tardiness  of  repair  is  also  due  to  the  bony 
substratum  on  which  rest  the  soft  parts ;  for  it  is  a  matter  of  com- 
mon observation  that  open  w^ounds  of  large  extent  situated  near  tlie 
surface  of  broad  bones  are  slow  to  heal ;  examples  of  this  are  seen 
on  the  cranium,  scapula,  and  the  front  of  the  tibia.  The  slowness 
in  cicatrizing  over  sach  parts  is  due  to  the  absence  or  paucity  of 
blood-supply  from  beneath;  the  material  for  repair  must  be  derived 
from  tlio  marginal,  or  surrounding  vessels.  In  consequence  of 
this  disposition,  cicatrization  may  occur  at  normal  rate  in  the 
peripheral  parts  of  the  wound,  while  centrally,  the  process  pro- 
ceeds slowly  or  is  at  a  standstill.  After  a  long  period  the  wound 
ma}^  wholly  heal;  the  remaining  cicatrized  surface  is  dry,  hard, 
immovable,  gloss}^  and  hairless.  Its  sensibility  is  perverted;  it 
may  be  almost  destitute  of  feeling;  or  it  may  be  the  site  of  pain, 
in  consequence  of  compression  of  the  nerves  which  have  devel- 
oped in  the  scar,  or  which  have  reached  to  it  and  been  arrested 
there  by  the  hard  texture  of  the  cicatrix.  Two  such  cases  have 
fallen  under  the  writer's  observation,  in  which  extensive  scars 
had  followed  lacerated  wounds  of  the  scalp.  The  large  scars 
remaining  after  healing,  especially  in  one  case,  were  painful;  or 
at  least,  were  the  seat  of  disagreeable  sensations,  which  the 
patient  could  not  clearly  describe,  yet  they  w^ere  the  source 
of  constant  torment.  It  should,  also,  be  remarked  that  the 
patients,  having  such  painful  cicatrix,  manifested  some  psychical 
peculiarity  bordering  on  insanity;  and  it  was  not  improbable 
that  along  with  the  injury  of  the  scalp  there  also  occurred  slight 
cerebral  concussion,  sufficient  to  cause  change  of  mental  character. 
Since  such  patients  localize  their  trouble  in  the  scar,  it  is  justi- 
fiable to  remove  the  latter,  and  replace  it  by  sound  structure  bor- 
rowed from  the  adjacent  parts.  As  preliminary  to  such  operative 
work,  one  should  examine  and  study  the  parts  around  in  reference 
to  their  capability  of  lending  tissue  for  replacement;  and  in  this 


08  WOUNDS    OF    THE    Sf'ALP. 

matter  an  important  point  is  that  the  replacing  tissues  be  easily 
movable,  so  that  the  wound  made  in  them  can  be  closed.  It 
being  decided  where  it  is  best  to  obtain  the  structure,  one  traces 
off  a  portion  somewhat  greater  in  extent,  if  possible,  than  the 
vacant  place.  Since  this  replacing  flap  must  be  twisted  in  order 
to  reach  and  occupy  the  breach,  it  should  be  so  chosen  and  situ- 
ated tiiat  its  base  siiall  be  twisted  as  little  as  possible;  and  this  is 
accomplished  by  incising  the  flap  from  alongside  of  the  vacant 
breach.  The  breach  must  now  be  jn-epared  b}"  the  removal  of 
the  cicatrized  structure;  and  if  the  surface  is  yet  unhealed,  then 
the  indolent  granulations  should  be  pared  off*,  and  when  bleeding 
has  ceased,  the  replacing  flap  should  be  brought  into  its  destined 
site;  and  having  been  pressed  well  against  the  subjacent  surface, 
the  free  end  of  the  flap  must  be  fastened  to  the  contiguous  border 
by  metallic  sutures.  Should  the  flap  not  readily  reach  to  the 
opposite  border,  still  let  it  be  fixed  in  i)lace  bv  an  elongated 
suture;  and  thus,  if  the  flap  be  not  brought  in  contact  with  the 
adjacent  margin,  at  least  it  is  so  fixed  on  the  subjacent  parts  that 
it  becomes  united  to  them.  The  wound  left  whence  the  flap  was 
uplifted  must  next  be  closed  by  lateral  api>roximation;  to  do  tliis 
use  metallic  suture,  inserted  and  passing  a  half  inch  from  each 
margin.  When  this  amount  of  structure  is  included  in  the 
suture,  it  will  bear  much  traction  witlioiit  arresting  the  circulation 
through  it:  and  such  suture  will  uiaintain  apposition  of  the 
margins  until  they  have  cohered.  The  wounded  parts  must  be 
dressed  daily  if  suppuration  appears;  the  best  agent  for  dressing 
is  iodoform,  which  should  be  dusted  freely  over  the  surface. 

In  case  the  breach  is  so  extensive  that  it  cannot  be  wholly 
covered  in  the  manner  just  described,  then'  let  the  restoring 
material  be  carried  across  the  middle  of  the  breach ;  for,  done  in 
this  way,  the  remaining  uncovered  portions  will  be  reduced  to 
minimum  proportions  in  tlie  subsequent  healing  process. 
Througii  this  plastic  procedure  the  painful  scar  is  removed,  the 
breach  partly  or  wholly  covered  and,  through  the  growth  of  the 
hair,  the  patient  is  relieved  of  an  unsightly  mark.  Should  the 
operation  fail  to  wholly  close  the  breach  by  Jiair-covered  flaps, 
then  the  latter  may  be  supplemented  by  cuticular  flaps  according 
to  the  method  lately  introduced  by  Thiersch. 

A  form  of  contusion  next  to  be  considered  is  that  in  wliich 
there  is  subjacent  separation  of  a  portion  of  the  scalp,  or  injury 
in  which  there  has  been  lesion  of  structure  without  external 
opening.     In  these  cases  vessels  are  supposed  to  be  opened  from 


COXTUSIOX    OF    THE    SCALP.  69 

which  blood  is  extravasated  into  the  subcutaneous  breach ;  and 
this  effused  blood  is  the  phenomenon  which  distinguishes  this 
form  of  contusion,  and  which  claims  chief  attention  in  treatment. 
The  form  of  such  wound  is  rounded,  both  in  its  free  surface  and 
.its  boundaries;  and  its  content  of  blood  may  vary  from  a  small 
quantity  to  that  of  several  ounces.  The  dimensions,  though  they 
can  be  estimated  with  the  eye,  can  be  more  accurately  determined 
through  touch,  by  which  the  consistence  of  the  swollen  part  is 
learned. 

The  contusion  with  ecchymosis  of  blood  is  often  seen  on  the 
head  of  the  new-born  child;  sometimes  it  is  of  very  great  size. 
There  are  two  kinds:  one  in  which  there  is  a  distinct  cavity 
filled  with  blood;  and  a  second  form,  in  which  the  blood  enters 
and  is  disseminated  through  the  tissues  of  a  portion  of  the  scalp. 
In  the  first  case  there  is  a  well-defined  sac  of  blood,  usually 
liquid,  and  which  has  arisen  from  subcutaneous  laceration  and 
loosening  of  the  pericranium,  in  wdiich  vessels  are  torn  and  their 
blood  poured  into  the  sac-like  cavity  which  has  thus  accidentally 
arisen.  This  form  of  extravasation,  named  cephalhaematoma,  in 
the  opinion  of  trustworthy  students  of  parturition,  arises  from  the 
passage  of  the  child's  head  through  a  rigid,  unyielding  os  uteri, 
which  displaces  and  so  slides  the  scalp  on  the  cranium  that  the 
vessels  are  torn  and  empty  their  blood  into  the  loosened  space. 
That  this  is  the  way  that  such  extravasation  is  created  is  proven 
by  the  fact  that  it  has  been  seen  in  births  in  which  the  foetus 
presented  by  its  feet  or  breech.  The  contained  blood  is  dark, 
grumous,  and  not  coagulated.  This  tumor  is  often  so  large  as  to 
deform  the  head  of  the  child.  The  tumor  is  compressible, 
slightly  movable,  and  its  liquid  content  evident  to  the  touch. 
As  John  Hunter  mentions,  the  pulsation  of  a  subjacent  fontanel 
may  be  transmitted  to,  and  through,  such  tumor,  and  give  the 
semblance  of  an  aneurism.  Where  an  artery  of  some  size  has 
been  opened  and  communicates  with  the  tumor,  the  case  is  very 
analogous  to  a  false  aneurism;  however,  the  pulsation  in  such 
tumor  usually  soon  disappears.  The  best  treatment  of  such 
tumor  when  small  is  slight  compression,  and  should  the  blood 
not  disappear  after  some  days,  then  a  slight  incision  may  be 
made  in  the  dependent  part  of  the  tumor,  and  the  blood  be 
scjueezed  out,  and  tlie  wound  closed  under  an  iodoform  dressing. 
As  a  rule,  however,  non-interference  is  the  safer  plan,  since,  if  the 
tumor  be  opened,  suppuration  is  apt  to  appear  in  the  sac,  and 
then  the  healing  becomes  prolonged  and  tedious.     The  author 


70  WOUNDS    OF    THE    SCALP. 

has  found  that  })aiiiting  such  tumor  with  the  tincture  of  iodine 
accelerates  the  absorption  of  its  contents.  As  before  said,  an 
accompaniment  of  the  tumor  is  tliat  the  pericranium  is  often 
detached  to  some  extent;  and  where  this  detachment  continues 
long  through  the  non-removal  of  the  effused  blood,  then  there, 
arises  a  slight  growth  of  bone  which,  wall  like,  marks  the 
former  site  of  the  ce])halhaematoma.  This  osteophyte  or  bone 
growth  is  so  slight  in  amount  that  it  gives  no  trouble. 

A  second  form  of  contusion,  occurring  in  the  foBtal  scalp, 
presents  itself  in  those  cases  of  cephalic  presentation  in  which, 
after  the  ru])ture  of  the  membranes,  the  child's  head  is  forced  for 
many  hours  against  the  uterine  mouth;  in  this  delayed  deliver}^ 
a  portion  of  the  scalp  is  pushed  through  and  constricted, 
cord-like,  by  the  unyielding  os  uteri.  The  final  result  of  such 
constriction  is  that  the  blood  is  extravasated  and  disseminated 
through  the  part,  so  that  after  birth  there  is  present  a  large 
tumor,  well  marked  off  from  the  adjacent  scalp.  This  tumor, 
slightly  elastic  and  compressible,  differs  in  consistence  from  the 
preceding  form,  in  which  the  content  was  grumous  blood;  for 
though  the  swelling  is  due  to  effused  blood,  yet  tlie  latter  is  not 
contained  in  a  sac  or  common  cavity.  This  more  solid  form  of 
contusion  of  the  foetal  scalp  is  seen  in  the  majority  of  new-born 
infants  as  an  inevitable  incident  of  birth,  yet  it  is  seldom  suffi- 
ciently grave  to  demand  attention;  on  the  contrary,  however,  the 
lesion  is  sometimes  so  severe  that  the  vitality  of  the  part  is  nearly 
or  quite  destroyed,  and  then  suppuration  or  sloughing  follows. 
Where  conditions  are  present  which  portend  this,  an  attempt 
must  be  made  to  prevent  such  ill  events.  For  this  |)urpose  gentle 
friction  should  be  daily  made  over  the  part;  or,  as  Hunter  teaches, 
"the  best  stimulus  is  pressure,  which  if  urged  beyond  the  point 
of  ease,  sets  the  absorbents  of  the  part  to  work."  Such  pressure 
may  be  made  by  means  of  an  elastic  bandage,  but  it  should  be 
slight,  lest  the  absorbing  vessels  be  occluded  or  retarded  in  their 
work.  As  a  general  rule,  however,  the  contusions  met  with  in 
the  scalp  of  tli^  new-born  rarely  demand  any  treatment;  the 
superabundant  forces  stored  up  in  the  nursling  are  adequate  to 
the  vanquishing  of  most  of  the  accidents  which  accompany  its 
birth. 

Besides  the  wounds  in  the  infant  just  described,  contusion  with 
concealed  extravasation  of  blood  is  met  Avith  in  subjects  of  any 
age,  as  the  result  of  violence.  In  similar  contusion  met  with  in 
other  parts  of  the  body,  the  ecchymosed  blood  is  partly  or  wholly 


COXTUSTOX    OF    THE    SCALP.  •  1 1 

clotted;  yet  in  such  injury  in  the  scalp,  the  effused  blood,  similar 
to  what  occurs  in  the  child,  does  not  coagulate,  but  remains 
semi-fluid  or  grumous  in  character.  The  coagulation  of  blood, 
according  to  Hunter,  is  due  to  its  being  alive;  and  non-coagulation, 
to  the  blood  being  dead.  Bruecke  refers  fluidity  to  some  influence 
emanating  from  the  coats  of  the  containing  vessels;  while 
Richardson  referred  the  fluidity  of  the  blood  to  ammonia,  which 
he  claims  is  present  in  the  circulating  blood.  Richardson  received 
a  premium  for  the  solution  of  a  problem  yet  unsolved.  Hunter 
was  probably  not  far  from  tlie  truth;  since,  as  he  observed,  such 
licjuid  blood  is  often  attended  by  inflammation  aud  suppuration, 
such  as  might  arise  from  a  foreign  body. 

Another  important  fact  to  be  noted  in  connection  with  such 
injury  is  that  it  often  deceives  the  touch,  and  is  mistaken  for  a 
fracture  with  depression  of  bone.  The  deception  arises  from  the 
sinking  of  the  part  under  pressure,  and  from  the  hardened  tissues 
which,  as  an  abrupt  wall,  surround  and  separate  the  ecchymosed 
blood  from  the  adjacent  parts.  The  careful  observer  learns  to 
distinguish  sucli  contusion  from  depressed  fracture  by  the 
circumstance  that  the  bounding  margin  in  fracture  is  more 
sharply  defined  than  in  mere  contusion;  and  in  the  latter  the 
boundary  is  inclined  toward  the  cavity.  To  avoid  error,  in  some 
cases,  much  tactile  experience  is  demanded.  In  the  case  of 
fracture  the  causal  violence  is  greater  than  in  uncomplicated 
contusion,  and  the  patient's  condition  is  sucli,  in  most  cases,  that 
some  grave  injury  may  be  inferred;  but  in  contusion  there  is 
rarely  any  enduring  encephalic  complication;  if  anyj;hing,  it  is 
merely  a  transient  concussion  of  the  brain. 

Where  the  effused  blood  is  small  in  quantity,  no  special 
treatment  is  required ;  slight  compression  of  the  part  is  sufficient; 
such  compression  is  especially  indicated  on  the  forehead,  where 
it  has  appeared  to  the  writer  that  the  effused  blood  coagulates 
and  becomes  organized  oftener  than  in  the  hairy  scalp;  and  in 
such  case,  though  the  clot  be  somewhat  reduced  in  amount  by 
compression,  yet  as  a  rule,  some  of  it  remains  as  a  discernible 
deformity.  As  just  said,  in  slight  cases  little  or  no  treatment  is 
needed,  but  if  a  large  amount  of  blood  be  effused,  and  which 
remains  liquid,  then  it  is  proper  to  consider  this  as  a  foreign  body 
which  should  be  removed.  This  work  of  removal  should  be 
done  with  much  care;  and  for  this  purpose,  first  cleanse  the  part 
carefully,  and  then,  at  some  point  best  situated  for  the  evacuation, 
make    a   valvular   incision    and,  having  forced    out  the  blood 


tJ.  WOrXDS    OF    THI-:    SCALP. 

close  the  wound  made  with  iodoform  dressing.  In  forcing  out 
the  blood,  let  tliis  bo  so  done  as  not  to  disturb  tiie  torn  vessels  and 
cause  new  bleeding  in  the  cavity.  If  tlie  blood  removed  has 
become  putrid,  a  suppuration  is  sure  to  arise,  and  then  it  is 
necessary  to  open  the  cavity  freely,  scrape  off  and  cleanse  its 
walls,  dust  these  with  iodoform  and  close  again;  thus  doing,  it  is 
sometimes  possible  to  obtain  healing  with  but  slight  suppuration. 

A  matter  of  importance  to  the  patient  in  the  several  cases  of 
contusion  considered,  is  whether  the  hair  Avill  be  lost  over  the  site 
of  injury;  in  nearly  all  cases  he  can  be  assured  that  no  such  loss 
will  occur;  only  where  there  has  been  suppuration  and  destruction 
of  tissue  is  tliere  loss  of  hair  in  the  part. 

Occasionally  the  coagulated  blood  remains  and  becomes  the 
starting-point  of  a  fibrous  growth;  such  growth  is  oftenest  seen 
on  the  forehead,  and  may  so  interfere  with  the  head-dress  as  to 
require  attention.  A  contusion  may  occlude  the  outlet  of  seba- 
ceous glands,  which  are  numerous  in  tlie  scalp,  and  thence  an 
atheromatous  tumor  can  arise.  Again,  w'here  tlio  content  is 
non-coagulated  blood,  the  containing  cavity  may  remain  and 
be  trap.sformed  into  a  cyst.  Such  cyst  rarely  attains  to  great 
dimensions;  and  hence  will  not  require  surgical  interference 
unless  it  interfere  with  tlie  subject's  dress;  in  that  case  it  may  be 
removed.  The  same  advice  may  be  given  in  regard  to  tlie  fibrous 
growtli  mentioned  above.  If  such  benign  development,  wlietlier 
fluid  or  solid,  remain  undisturbed,  it  will  continue  without  pain, 
or  increase  or  decrease  in  volume,  for  an  indefinite  period.  The 
continued  tranquillity  of  such  formation  is  often  disturbed  by  the 
patient's  solicitude  and  desire  that  his  figure  should  conform  to 
that  sketched  by  his  vanity;  and  especially  is  the  existence  of 
such  develoiDment  menaced  by  the  knife  of  some  new  recruit  to 
tlie  ranks  of  surgery;  and  though  the  removal  is  an  easy  matter, 
the  recovery  is  not  always  so;  for  through  some  untoward 
circumstance,  the  healing  may  be  long  and  vexatious,  and  the 
finality  of  an  attempt  to  improve  a  feature  may  disappoint  both 
subject  and  surgeon. 

Gunshot  Wounds;  General  Remarks. — Human  civilization  often 
boasts  of  its  advancement,  and  with  much  satisfaction  prides 
itself  on  a  near  approacli  towards  perfection;  yet  when  one 
regards  the  sanfruinarv  battle-fields  of  modern  vears,  on  which 
life  was  wantonly  sacrificed,  it  is  evident  that  many  vestiges  of 
the  worst  barbarism  of  the  untamed  era  of  our  race  still  remain. 
And  even  should  the  optimistic  hope  be  entertained  that  humanity 


GUXSHOT    WOUXDS;    GENERAL    KEMAEKS.  73 

will  sometime  reach  a  stage  of  reason  in  which  w^ar  shall  cease  its 
deadly  w^ork,  yet  it  is  more  than  probable  that  even  in  peace  the 
fatal  firearm  will  continue  in  use  as  an  agent  with  which  the 
human  body  will  voluntarily  or  involuntarily  be  mutilated;  and 
hence  that  hereafter,  as  heretofore,  gunshot  wounds  will  constitute 
an  important  chapter  in  surgery.  The  human  body  is  vulnerable 
to  the  missile  projected  by  gunpowder,  from  the  scalp  to  the  sole 
of  the  foot;  among  modern  men  there  is  no  one  wdio  has  acquired 
immunity  through  armor  or  Stygian  water ;  a  Charles  the  Tw^elfth, 
if  in  range  of  a  musket  ball,  falls  a  victim ;  the  sentry  Destiny, 
whom  the  king  fancied  to  be  his  constant  guardian,  on  one 
occasion  slumbered  at  his  post,  and  the  royal  hero,  as  readily  as 
a  pawn,  was  swept  from  the  chessboard  of  battles,  on  which  he 
had  played  the  intangible  victor  so  many  times. 

The  gunshot  wound  is  caused  by  a  missile  discnarged  by  an 
instrument  known  as  a  gun  or  firearm;  of  such  instruments  there 
are  many  kinds,  which  vary  in  form  and  size  from  that  which  is 
very  small  to  that  W'hich  is  of  stupendous  proportions,  and 
intermediately  there  are  many  gradations.  Also,  there  is  an 
infinite  variety  of  missiles  corresponding  to  the  projecting  instru- 
ment. The  gun  may  have  a  smooth  caliber,  or  the  inner  surface 
may  be  rifled  with  spiral  furrows;  these  furrows  are  designed  to 
impart  a  whirling  movement  to  the  ball,  so  that  the  latter,  planet- 
like, wdiile  moving  in  its  course,  likewise  revolves  about  its  center. 
Thus  moving,  the  ball  acquires  a  double  endowment  of  doing 
violence.  Gunshot  missiles  vary  in  form,  volume  and  in  com- 
ponent material.  The  form  may  be  round,  which  was  the  only 
one  in  use  until  recently;  in  modern  times  a  ball  of  elongated 
and  oval  form  has  been  introduced.  The  best  type  of  this  is  the 
minie  ball,  which  is  egg-shapen.  The  ball  of  this  shape  acts 
somewhat  as  a  wedge,  and  thus  by  splitting  the  structure  of  the 
body  on  which  it  strikes,  it  acts  more  destructively.  The  wedge- 
like smaller  end  of  such  ball  striking  a  long  bone  may  split  it 
from  end  to  end,  but  a  ball  of  rounded  form  causes  a  more 
localized  fracture  with  numerous  fragments.  The  conical  ball 
traversing  rapidly  the  soft  parts  leaves  a  w^ound  similar  to  an 
incision,  but  the  round  one  leaves  a  more  circular  track.  As  to 
component  material,  the  gunshot  missile  may  be  of  lead,  copper,  or 
somemixed  metal;  the  leaden  ball isthemost  usual  kind.  Thegun 
may  be  loaded  with  powder  alone,  and  the  violence  done  by  the 
firing  will  depend  on  the  condition  w^h ether  the  powder  has  been 
rammed  dowm  or  only  lies  loose  in  the  gun  barrel,  for  when  forced 


74  WOUNDS    OF    THE    SCALP. 

well  down,  firing  at  short  range  may  cause  much  violence;  a  charge 
of  powder  fired  at  a  short  distance  into  the  abdomen  of  a  man 
caused  immediate  death.  Dupuytren,  wlio  saw  the  case,  records 
that  a  large  opening  was  made  through  the  abdominal  wull, 
the  intestines  were  wounded  and  the  wadding  of  the  powder  was 
lodged  in  the  abdominal  cavity.  Where  no  wadding  is  used,  the 
discharged  powder,  says  Dupuytren,  wounds  the  skin  severely. 
The  suicide  in  his  haste  and  desperation  has  sometimes,  luckily 
for  his  life,  forgotten  to  place  the  ball  in  his  weapon,  and  there 
resulted  only  a  severe  powder  wound  of  his  face  or  mouth. 

Besides  the  missile's  form,  its  magnitude  and  velocity  cooper- 
ate as  im})ortant  fa-^tors  in  the  amount  and  character  of  the 
violence  done  by  it.  For  example,  if  a  small  and  a  large  ball 
move  with  equal  ]>ropulsive  force  at  a  long  distance,  the  small 
one  will  do  much  more  injury  than  tiie  large  one;  at  a  great 
distance  the  small  ball  will  penetrate,  or  even  pass  through  a 
human  body,  while  the  larger  may  fall  as  a  spent  ball  on  the 
hither  side  of  tlio  target.  Again,  a  ball  moving  at  a  slow  rate  of 
motion  injures  more  than  one  moving  rapidly,  and  in  case  the 
two  sever  tissues,  the  one  moving  rapidly  makes  its  way  rather 
by  cutting  than  by  tearing;  but  the  one  moving  slowly  does  so 
by  tearing  rather  than  by  cutting;  in  the  former  case,  the  wound 
made  resembles  an  incised  one,  while  the  latter  resembles  a 
lacerated  one.  The  Swiss  government,  in  equipping  its  military 
forces  with  guns  which  can  do  work  of  violence  at  a  great  dis- 
tance, has  utilized  these  facts;  tlieir  guns  carry  small  balls. 

John  Hunter,  who  had  opportunities  for  the  study  of  gunshot 
wounds  while  holding  the  position  of  staff-surgeon  in  the  British 
army,  says  that  the  wound  produced  by  the  bullet  is  a  contused 
one.  He  remarks  that  from  "such  contusion  there  is  most 
commonly  a  part  of  the  solids  surrounding  the  wound  deadened, 
as  the  projecting  body  (bullet)  forced  its  way  through  the  solids, 
which  (tissue)  is  afterwards  thrown  off  in  the  form  of  a  slough, 
and  which  prevents  such  wounds  from  healing  by  the  first 
intention,  from  which  circumstance  the  most  of  them  must  be 
allowed  to  suppurate."  Yet  he  observes  that  the  amount  of 
contusion  differs,  the  difference  arising  from  the  variety  in  the 
velocity  of  the  projectiles.  Instead  of  the  velocity,  it  is  rather 
the  piomentum,  which  is  a  component  of  the  velocity  and  tlie 
weight  of  the  missile,  that  figures  in  the  work  done  by  the  missile; 
for  the  weight  of  the  ball  has  an  important  bearing  on  the  injury 
inflicted.     To  illustrate  this,  a  large  pistol  ball  impelled  by  a 


GUNSHOT    WOUNDS    OF    THE    SCALP    AND    SKULL.  75 

small  charge  of  powder  and  striking  the  trunk  of  a  man  would 
cause  him  to  fall,  though  the  injury  done  to  his  body  was  only 
slight,  but  with  the  same  charge  of  powder  a  small  ball  would 
penetrate  and  probably  pass  through  the  body;  in  the  former 
case  the  subject  would  be  stunned  and  disabled  for  a  short  time, 
while  in  the  latter  he  might  be  killed.  Those  selling  arms  are 
familiar  with  these  facts,  and  advise  their  purchaser  to  buy  this 
or  that  piece  according  to  the  purpose  intended.  To  such  refine- 
ment have  the  agents  of  destruction  been  brought! 

Gunshot  Wounds  of  the  Scalp  and  Skull — The  victim  of  a  gun- 
shot wound  of  the  head  is  fortunate  if  the  lesion  is  limited  to 
the  scalp,  but  in  the  case  of  large  balls,  or  the  fragment  of  a 
bomb  causing  the  wound,  then  the  injury  commonly  extends  to 
more  important  parts  which  are  adjacent,  viz.,  the  cranium  and 
the  encephalon.  But  where  the  injury  has  arisen  from  a  small 
ball  which  did  not  pass  deeper  than  the  structures  of  the  scalp, 
the  wound,  in  nearly  all  cases,  is  an  unimportant  one. 

The  varieties  in  the  form  of  the  wound  produced  by  a  ball  arc 
here,  as  well  as  elsewdiere,  the  following: — • 

1.  An  open  wound  caused  by  the  missile  merely  impinging 
against  the  surface  in  its  passage  and  dividing  the  tissues  to  a 
greater  or  smaller  extent,  and  owing  to  the  convex  form  of  the 
head,  this  wound  must  necessarily  be  short,  seldom  equaling,  and 
almost  never  exceeding,  two  inches  in  length. 

2.  The  ball  may  enter  and  escape,  the  intermediate  passage, 
canal-like,  lying  beneath  the  surface.  Such  tubular  wound,  as  a 
rule,  is  not  more  than  two  inches  long;  an  exception  is  where  the 
ball  passes  deeper,  and  striking  the  surface  of  the  skull,  it  is 
deflected  from  a  straight  course,  and  in  this  case  the  point  of 
emergence  may  be  at  any  distance  from  that  of  entrance. 
Though  the  ball  has  escaped  from  the  canal,  yet  not  unfrequently 
it  carries  along  with  it  and  leaves  some  foreign  material  detached 
from  the  head-dress  or  covering  of  the  scalp.  The  walls  of  this 
wound  are  in  contact,  so  much  so  that  fluid  injected  into  one  end 
would  with  difficulty  escape  from  the  other  end,  especially  if  the 
missile  be  small. 

3.  The  ball  may  not  escape,  but  remain  imbedded  in  the  scalp, 
and  then  the  ball  lies  at  the  bottom  of  a  blind  canal,  and  with 
it  may  be  detritus  from  the  head-dress.  Another  species  of  blind 
ending  shot-canal  is  that  in  whicli  the  missile  rebounds  and 
escapes  where  it  entered;  contact  with  the  skull  might  cause  such 
rebound  of  the  missile. 


76  WOUNDS    OF    THE    SCALP. 

4.  Finally,  there  is  a  variety  in  which  there  is  no  external 
wound,  nevertheless,  the  structures  underneath  the  skin  are 
severely,  perhaps  totally,  killed;  the  integument  nuiy  also  be 
destroyed.  Such  injury  on  the  head  would  necessarily  involve 
parts  deeper  than  the  scalp;  the  skull  might  be  injured  as  well  as 
the  brain  itself.  The  explanation  of  the  manner  in  which  this 
wound  is  ])roduced  has  been  a  matter  of  much  study  among  those 
who  have  studied  gunsliot  wounds.  As  no  mark  on  the  surface 
remains  to  indicate  the  contact  of  the  projectile,  the  wound  has 
been  referred  to  the  action  of  the  suddenly  displaced  air,  and 
thence  arose  the  name  of  windshot  Another  explanation  offered 
by  Rust,  quite  the  opposite  of  this,  is  that  the  ball  passing  near 
the  surface  causes  a  vacuum  towards  which  the  structures  are  so 
violently  displaced  as  to  wound  them.  Neither  of  these  explana- 
tions is  deemed  satisfactory.  The  one  now  accepted  is  that  the 
ball  actually  strikes  the  surface  in  a  glancing  way,  and  in  so 
doing  communicates  a  part  of  its  momentum  to  the  parts  which 
thereby  become  wounded. 

The  projectile  in  its  passage  through  the  air  describes  a  uni- 
form curve  in  accordance  with  laws  so  unvarying  and  so  well 
known  to  the  mathematician  that  the  final  end  or  stopping  point 
of  the  ball  can  be  definitely  estimated  and  determined.  Yet  in 
the  human  body,  constituted  as  it  is  of  materials  of  such  varying 
consistence  and  density,  the  ball,  striking  some  hard  structure,  is 
caused  to  stray  from  its  previous  direction;  and  should  such 
impact  be  repeated,  then  the  course  of  the  ball  is  com2)osed  of 
broken  lines,  of  which  mathematics  find  no  analogue  in  the  sec- 
tions of  the  cone,  straight  or  curved  line.  The  ball  glancing 
from  point  to  point  leaves  a  path  vague,  erratic  and  incalculable. 
Thus  it  has  followed  the  convex  surface  of  the  skull,  and  then 
emerging  has  reentered  the  trunk  and  continued  its  wandering 
there.  A  ball  has  struck  tlie  chest  wall,  and,  without  entering  it, 
has  passed  quite  around  the  thorax,  its  path  lying  just  under  the 
skin.  And  not  alone  has  such  wandering  followed  convex  sur- 
faces, it  has  followed  concave  ones;  this  has  occurred  within  the 
cranial  and  thoracic  cavities;  thus  a  bullet  having  entered  the 
thorax  has  confined  its  course  to  the  inner  surface  of  the  ribs,  and 
left  the  adjacent  lung  intact.  The  deflection  of  a  ball  from  a 
straight  course  occurs  when  it  passes  from  a  rarer  to  a  denser 
medium;  this  is  well  illustrated  on  the  water  when  a  ball  is 
so  projected  as  to  bound  from  point  to  point  (ricochet)  on 
the  water.     The  varying  structures  of  the  human  body  do  not 


GUXSHOT    WOUNDS    OF    THE    SCALP    AND    SKULL.  77 

permit  any  regular  rebounding  as  occurs  in  the  ricochet  of 
the  naval  gunner;  for  the  latter  is  so  nearly  master  of  it  that  he 
can  utilize  it  in  his  destructive  work.  In  the  human  body,  like 
many  things  familiar  to  our  observation  of  humanity,  though  it 
may  start  straight,  yet  it  may  end  very  crookedly. 

The  form  of  the  entrance  opening  and  that  of  the  exit,  where 
this  exists,  will  here  be  considered.  As  a  rule  the  edges  of  the 
entrance  opening  are  turned  inwards;  if,  however,  the  ball  were 
moving  with  great  sj^eed,  then  the  edges  might  be  cut  so  abruptly 
as  not  to  turn  inwards.  Where  the  ball  does  not  emerge  from 
the  body,  its  course  often  becomes  a  difficult  problem  to  solve. 
In  such  cases  the  position  and  direction  in  which  the  inverted 
edges  lie  are  indices  of  the  direction  in  which  the  ball  started. 
Besides  the  eversion  of  the  exit  opening,  it  is  larger  than  that  of 
the  entrance,  and  this  is  caused  by  the  missile  carrying  along 
with  it  foreign  material  caught  outside  of  the  body;  or  such 
enlarging  material  may  be  derived  from  the  tissues  through 
which  the  missile  passes;  for  the  shot-canal,  especially  when  the 
ball  moves  with  great  speed,  is  not  caused  by  misplacement  alone 
of  the  parts  traversed,  but  the  structures  are  likewise  severed. 
The  opening  of  escape  may  also  be  enlarged,  or  rendered  irregu- 
lar, through  the  ball  having  been  altered  in  its  form,  through 
contact  with  some  bone  or  tendon.  From  such  contact  the  ball 
might  also  be  split  and  the  fragments  escape  at  different  points; 
or  one  fragment  only  escajDing,  the  exit  point  might  be  smaller 
than  that  of  the  entrance.  The  entrance  point  may  be  distin- 
guished sometimes  by  marks  of  powder;  and  such  marks  would 
indicate,  also,  proximity  of  the  discharging  weapon. 

From  the  facts  and  circumstances  already  detailed,  the  diag- 
nosis of  the  gunshot  wound  can  readily  be  made  out  in  most 
cases;  in  cases  of  obscurity  the  history  of  the  accident  will  usually 
remove  any  doubt  from  the  mind  of  the  diagnostician. 

The  prognosis  of  the  gunshot  wound  will  depend  somewhat 
on  the  extent  of  the  injury,  but  more  on  the  situation  and  nature 
of  the  parts  wounded;  certain  regions  of  the  body  may  be  trav- 
ersed by  a  gunshot  wound,  and  but  slight  injury  occur  to  the 
subject;  should  the  ball  leave  foreign  matter  in  its  track,  then  the 
wound  becomes  much  more  grave.  But  if  parts  necessary  to  life 
are  injured,  the  wound  becomes  a  perilous  one,  the  peril  depend- 
ing, in  case  the  head  and  chest  be  the  site,  more  on  the  foreign 
matter  carried  into  the  tissues,  than  on  the  wound  made  in  them. 
In  the  abdomen,  besides  the  foreign  matter  which  the  missile 


/b  WOUNDS   OF    THi:*  SCALP. 

may  introduce,  a  wound  of  the  bowel  may  lead  to  tlie  effusion  of 
intestinal  content,  and  these  invisible  contingencies  add  greatly 
to  the  wound;  and  though  modern  surgery  would  expose  them 
to  sight  by  exploratory  incision,  yet,  thus  far,  the  danger  of  such 
injury  has  only  been  but  partially  diminished. 

The  wanderings  which  the  ball  may  indulge  in,  and  the  impos- 
sibility often  of  deciding  what  structures  have  been  wounded, 
render  it  impossible  in  many  cases  to  predetermine  the  final  result 
of  a  gunshot  wound;  so  that  when  the  ball  has  entered  the  head, 
chest,  or  abdomen,  the  first  few  days,  and  sometimes  the  first  few 
hours,  are  pregnant  with  momentous  issue  to  the  unfortunate 
victim.  xVnd  the  prophetic  art  of  the  attending  surgeon  on  such 
occasion  is  often  most  successfully  exercised  if  his  prognostic 
utterances  are  couched  in  the  jihraseof  the  Delphic  oracle,  which 
admits  of  opposite  interpretations;  for  the  medical  seer  when  he 
casts  his  prognostic  horoscope  very  often  descries  no  absolute 
certainties;  when,  however,  the  lit-ld  is  limited  to  that  of  the 
sim[)le  gunshot  wound  of  the  scalp,  there  is  rarely  any  occasion 
for  ominous  foreboding,  for  recovery  may  always  be  expected. 

Treatment. — In  considering  the  treatment  of  gunshot  wounds 
of  the  scalp,  we  commence  with  tlie  simplest  form,  viz.,  the  open 
shot  canal,  which  is  a  furrow  in  the  surface  of  the  scalp.  Tlie 
depth  of  this  may  vary  from  that  of  a  mere  abrasion  to  a  wound 
involving  the  whole  thickness  of  the  parts,  but  in  every  case  the 
surgeon  has  the  advantage  of  being  able  to  inspect  the  wound, 
whether  it  is  smoothly  cut  or  lacerated,  and  he  also  sees  wliether 
the  surface  is  free  or  not  from  foreign  impurities.  If  impurities 
be  present,  they  should  be  removed  by  irrigation  with  an  anti- 
septic fluid;  and  if  the  edges  be  irregularly  torn  or  limljriated, 
they  should  be  rendered  smooth  by  trimming.  This  work  being 
done,  if  the  edges  can  be  approximated  by  sutures  without  much 
tension,  this  should  be  done;  the  part  is  next  to  be  sprinkled  with 
iodoform,  and  lastly  covered  with  lint.  In  this  case  the  wound 
has  1)een  converted  into  a  simple,  incised  one,  and  the  healing 
should  be  immediate  and  leave  but  a  slight  trace  in  the  form  of  a 
linear  scar.  In  case  the  wound  is  so  broad  that  it  cannot  thus  be 
closed,  partial  closure  should  be  made,  either  by  suture  or  by 
tying  the  hair  across  the  breach,  as  already  described;  and  tlien 
dress  with  iodoform  and  occluding  lint;  thus  treated,  the  least 
possible  scarring  will  remain. 

In  the  second  form  of  wound,  viz.,  tubular  and  open  at  both 
ends,  when  it  is  superficial,  the  subjacent  track  will  be  indicated 


GUNSHOT   WOUNDS    OF    THE    SCALP    AND    SKULL.  79 

by  some  discoloration  of  the  skin;  also,  if  pressure  be  made  along 
this  track  a  crepitant  or  emphysematous  sensation  will  often  be 
perceived,  and  becomes  a  diagnostic  aid.  Besides  this,  the  nor- 
mal consistence  of  the  parts  may  be  altered.  If  it  be  probable 
that  some  foreign  material  has  lodged  in  the  canal,  a  careful 
search  should  be  made  for  the  same  with  a  bullet  sound,  and  if 
found,  removed.  The  removal  can  be  done  by  cutting  down 
directly  on  the  body,  but  the  work  can  be  done  j)referably  in 
most  cases  by  means  of  forceps  introduced  through  the  opening 
of  the  canal,  viz.,  the  end  which  is  nearest  the  foreign  object. 
After  this,  the  canal,  if  sufficiently  permeable,  should  be  cleansed 
by  injecting  through  it  an  antiseptic  fluid.  This  injection  must 
not  be  done  too  violently,  lest  the  fluid  forsake  the  canal  and  be 
forced  into  the  adjacent  tissues.  This  preliminary  work  being- 
completed,  the  wounds  are  to  be  treated  as  any  simple  wound, 
and  the  whole  to  be  covered  with  lint  and  a  retaining  bandage. 
The  wounds  will  probabl}"  C|uickly  lieal,  with  only  a  slight  serous 
discharge  from  the  concealed  canal.  If  there  b«  indications  of 
hsemorrhage  in  the  canal  at  the  time  of  the  dressing,  it  would  be 
improper  in  most  cases  to  open  the  wound  to  find  the  opened 
vessel,  since  the  bleeding  could  be  arrested  by  a  compressive 
bandage  over  the  dressing.  If  later  there  occur  signs  of  suppura- 
tion in  the  canal,  which  would  be  indicated  by  circumscribed 
swelling,  the  canal  must  Ije  oj^ened,  and  having  been  cleansed,  it 
must  be  dressed  daily  with  iodoform. 

In  the  third  or  csecal  form,  in  which  the  canal  ends  blindly, 
at  its  bottom  the  missile  may  be  expected  to  be  found.  In  a  case, 
however,  of  a  gunshot  wound  of  the  chest  seen  by  the  author,  no 
ball  was  found  in  the  canal,  and  on  examination  it  was  discov- 
ered that  the  coat,  vest  and  outer  shirt  had  been  pierced,  but  the 
undershirt  was  intact;  the  undershirt  had  escaped  opening,  and 
been  forced  into  a  canal  two  inches  long,  and  then  the  missile 
had  been  dislodged  by  the  retraction  of  the  shirt.  From  this  the 
lesson  is  forcibly  taught,  always  to  examine  the  clothing  care- 
fully, both  with  the  view  of  learning  whether  it  has  been  pierced, 
and  if  so,  wdiether  the  ball  has  cut  and  carried  with  itself  some  of 
the  dress.  As  a  rule,  the  ball  will  lie  at  the  bottom  of  the  canal, 
and  can  be  detected  there  by  a  sound;  but  if  the  wound  will 
admit  the  finger,  the  latter  is  the  best  detective  both  of  the  ball 
or  any  adventitious  matter.  The  ball  having  been  removed,  it 
should  be  examined  as  to  its  form,  since  from  changes  in  this 
some  information  can  be  gained  concerning  injury  which  may 


80  WOUNDS    OF    THE   SCALP. 

have  been  done  to  the  skull.  P'rom  studies  of  the  change  of  the 
bullet's  form,  Bousquet,  in  1SS5,  announced  the  following:  "When 
the  point  is  flattened  it  denotes  that  the  bullet  struck  and  caused 
a  depression,  or,  along  with  depression,  the  bone  is  also  broken. 
When  the  bullet  is  depressed  on  one  side  and  is  cracked  on  the 
opposite  side,  this  indicates  that  the  bone  impinged  on  was  not 
broken.  A  lateral  depression  on  the  bullet  means  that  the  bone 
was  touched  and  only  depressed."  Instructed  by  these  facts,  it  is 
well  to  study  any  changes  visible  in  a  bullet  which  has  been 
extracted.  The  ball  being  removed,  dress  the  wound  according 
to  the  methods  alread}'  described. 

In  cases  in  which  the  ball  lies  concealed,  and  there  would  be 
great  difiiculty  in  removing  it,  the  better  course  is  to  let  it  remain. 
Such  practice,  however,  would  not  be  proper  where  the  ball  lies 
anywhere  on  the  cranial  vault,  since  its  removal  there  is  easily 
effected;  but  when  the  missile  is  lodged  in  the  structures  at  the 
base  of  the  cranium,  the  case  is  otherwise.  For  example,  in  the 
occipital  region,  a  ball  might  lie  in  the  trapezius  and  complexus 
muscles,  and  be  so  deeply  buried  that  it  Avould  be  extremely  hard 
to  find  it,  and,  if  found,  the  attempt  to  remove  it  would  cause 
great  laceration  and  injury  to  the  tissues.  Also,  if  buried  in  the 
temporal  fossa,  the  effort  to  extract  the  ball  would  be  attended 
with  much  violence;  hence,  in  gunshot  wounds  in  these  regions, 
non-interference  is  the  better  plan  for  the  patient;  yet  it  is  too 
rarely  followed,  since  the  surgeon  finds  it  difficult  to  withstand 
the  popular  clamor  that  the  ball  must  be  found.  Yielding  to 
such  mischievous  opportunity,  the  surgeon  has  too  often  forsaken 
the  line  of  duty  and  engaged  in  adventurous  work  which  has 
added  little  to  his  own  reputation,  and  still  less  to  the  welfare  of 
his  patient.  The  probe,  led  by  a  blind  guide,  has  often  wandered 
far  from  the  object  of  its  search,  and  caused  irreparable  injury. 
In  some  cases,  the  ball  which  lies  at  the  bottom  of  a  blind  canal, 
does  as  little  harm  in  the  body  as  it  would  outside  of  it.  In  all 
such  cases  abstention  is  urgently  indicated.  When  the  ball  is 
allowed  to  remain  in  the  tissues,  if  it  be  unaccompanied  by  any 
foreign  material,  it  does  not  awaken  much  reaction  in  the  parts 
contiguous;  it  is  an  aseptic  agent  which  has  been  purified  by  its 
passage  through  fire.  No  more  innocent  intruder  could  make 
its  ingress  into  the  tissues  of  the  body;  its  only  offensive  qualities 
are  its  weight  and  the  slight  pressure  which  it  makes  on  the  parts 
around.  The  resultant  irritation  awakens  a  formative  action  by 
which  a  cicatricial  capsule  is  thrown  about  the  ball;  especially,  it 


GUNSHOT    WOUXDS    OF    THE    SCALP   AND    SKULL.  81 

it  be  lodged  in  the  muscular  tissue;  but  in  more  yielding  structure, 
as  the  brain,  the  ball  may  sink  by  gravitation  from  its  first  place 
of  lodgment.  The  same  has  occurred  in  the  loose  structures  of 
the  axilla. 

The  fourth  form  of  gunshot  wound,  caused  by  the  lateral  or 
glancing  contact  of  a  large  ball,  is  often  a  grave  injury,  since  the 
parts  thus  wounded  are  often  wholl}''  destroyed;  and,  when  on  the 
scalp,  the  cranium  may  also  be  fractured.  Such  fracture  con- 
joined to  the  lesion  of  the  soft  parts,  is  extremely  perilous  to  life. 
Where  the  bone  is  probably  not  injured,  as  may  be  inferred  where 
depression  and  crepitus  are  absent,  then  the  treatment  is  directed 
to  the  use  of  means  calculated  to  save  or  restore  the  life  of  the 
injured  soft  parts.  For  this  purpose,  shave  the  part  and  apply  to 
it  a  paste  composed  of  balsam  of  Peru  and  iodoform.  This  com- 
pound, should  the  injured  parts  die,  resists  putrefaction  and  aids 
in  the  disinfection  and  drying  of  the  surface  covered  by  the  paste; 
and  thus  if  the  injury  does  net  involve  the  entire  thickness  of  the 
scalp,  the  outer  desiccated  layer  acts  the  part  of  a  scab,  under 
which  healing  occurs.  Such  healing,  however,  is  slow,  and  would 
rarely  complete  itself  under  the  protective  slough;  and,  therefore,  it 
is  better  that  the  latter  be  removed,  and  the  remaining  injured 
surface  treated  as  an  open  wound.  If,  however,  at  the  first  exam- 
ination of  such  injury  the  surgeon  is  convinced  that  the  parts  are 
wholly  killed,  then  any  attempt  to  restore  their  vitality  would  be 
irrational;  it  is  better  to  use  means  which  would  promote  detach- 
ment of  the  dead  structures;  and  for  this  use  moist  warmth,  by 
means  of  cataplasms  covered  with  oiled  silk.  And  if  ten  per  cent 
of  alcohol  be  added  to  the  liquid,  and  enough  of  carbonate  of  soda 
or  potash  to  render  it  highly  alkaline,  then  the  maceration  will 
be  best  effected.  After  the  dead  tissues  have  been  removed,  the 
remaining  wound  should  be  protected  by  moist  dressings;  and  if 
the  granulative  action  be  tardy,  a  slightly  stimulating  dressing 
should  be  used,  viz.,  a  five  per  cent  solution  of  alcohol.  In  case 
the  surface  to  heal  is  so  large  that  it  cannot  readily  close  by  cica- 
trization, then  the  surgeon  should  lend  assistance  by  some  of  the 
plastic  artifices  at  his  command;  for  this,  adjacent  tissue  may  be 
utilized,  either  by  complete  or  incomplete  approximation  of  oppo- 
site margins,  or  by  taking  a  flap  from  the  contiguous  parts  and 
placing  it  across  the  breach.  Should  these  methods  be  impracti- 
cable, then  the  work  of  closure  might  be  accomplished  by  means 
of  skin-grafting;  such  grafting  material  may  be  procured  from 
the  subject,  his  friends,  or  from  corpora  viliora,  as  the  frog  or 


82  WOUNDS    OF    THE    SCALP. 

dog:  the  dog,  it  is  said,  has  repaired  liis  master's  scarred  and 
hairless  scalp  with  hair-covered  derm.  Transplanting  grafts 
from  the  sheep  has  been  advised,  and,  in  fact,  trial  of  the 
same  has  been  reported;  yet  it  is  not  probable  that  the  api)endage 
inseparable  from  such  grafting  would  be  satisfactory  to  many 
heads,  though,  as  a  humorous  journalist  once  })ut  it,  it  niiglit  be 
the  "best  thing  that  many  heads  could  be  put  to."  In  tliis  work 
of  skin-grafting,  where  there  has  been  loss  of  the  entire  thickness 
of  the  scalp,  the  anremic  condition  of  the  surface  to  be  repaired 
will  be  more  apt  to  entail  failure  than  success;  should,  however, 
the  pericranium  be  intact,  the  peculiarly  disposed  vascularity  of 
this  membrane  would  insure  the  life  of  the  grafts;  for  tlie  numeri- 
cal superiority  of  the  veins  over  the  arteries  would  favor  conges- 
tion and  insure  an  abundant  supply  of  blood;  and  hence  the 
l)resence  or  absence  of  the  pericranium  has  no  small  bearing  on 
the  question  of  repair  by  the  method  of  grafting.  Instead  of 
using  the  entire  derm,  Thiersch's  epidermal  grafts  might  be  used. 
Gangreyie. — Gangrene  or  mortification  of  the  structures  of  the 
scalp  is  seldom  or  never  seen  as  a  primary  phenomenon;  a  fact 
due  to  the  abundant  supply  of  blood  to  these  parts;  in  this 
respect  the  head  contrasts  with  the  inferior  extremities,  so  often 
the  seat  of  mortification.  Besides  the  abundant  su[)ply  of  blood 
to  the  scalp,  its  position  is  unfavorable  to  stasis  or  congestion, 
which,  in  many  cases,  may  be  viewed  as  the  proximate  factor  in 
tiie  causation  of  gangrene:  the  crowded  vessels  in  the  lower 
limbs  exert  no  inconsiderable  pressure  on  the  parts  which  they 
traverse,  and  the  paradoxical  condition  is  present  of  starvation 
in  the  presence  of  excessive  nutrition;  but  in  the  scalp  the 
forces  of  the  heart,  assisted  by  gravitation,  avert  stagnation  of 
blood;  and  as  result,  if  the  structures  on  the  head  die,  it  is 
from  actual  antemia  due  to  some  mechanical  agency.  As  exam- 
ple of  such  case  may  be  cited  concussion,  in  which  the  vio- 
lence done  has  immediately  deprived  the  scalp  of  its  vitality, 
and  those  in  which  the  part  has  been  rendered  anaimic  through 
pressure.  The  cases  arising  from  sudden  violence  have  been 
sufficiently  considered.;  but  as  examples  arising  from  lack  of 
blood,  may  be  cited  those  cases  in  which  the  patient,  the  sub- 
ject of  some  debilitating  disease,  rests  the  head  in  one  position 
for  a  long  period ;  thus  a  patient  in  the  later  stages  of  typhoid 
fever  has  been  found  to  have  death  of  the  scalp  on  the  back  of 
the  head  on  which  he  has  lain  for  a  number  of  weeks.  This 
tendency  to  death  from  pressure  in  any  adynamic  disease  of  long 


GANGRENE.  bd 

duration,  should  be  borne  in  mind,  and  suitable  means  used  to 
avert  it.  As  means  to  avoid  such  gangrene,  let  the  head  rest  on 
an  air-cushion,  and  besides  having  its  position  changed  from  time 
to  time,  let  the  exposed  part  be  bathed  with  alcohol  containing 
corrosive  sublimate,  in  the  proportion  of  one  in  a  thousand.  If, 
notwithstanding  this,  the  part  dies,  then  the  detachment  of  the 
gangrenous  structures  should  be  favored  by  moist  warmth,  and 
the  ulterior  management  of  the  case  should  conform  to  advice 
before  given. 

Again,  fatal  anaemia  of  the  parts  may  be  induced  by  the 
careless  use  of  the  ice-bladder,  the  use  of  which  is  so  much  in 
vogue  in  the  treatment  of  injuries  of  the  head.  To  avoid  such 
ill  results,  the  heavy  fragments  of  ice  should  not  be  used,  but 
instead,  ice  which  has  been  finely  crushed;  or,  if  it  could  be 
obtained,  snow  might  be  used;  and  between  the  containing 
bladder  and  the  head,  a  layer  of  flannel  should  be  interposed; 
thus  the"  excessive  action  of  the  cold  will  be  prevented. 

Gangrene  of  the  scalp  may  arise  from  the  subcutaneous 
ravages  of  phlegmonous  erysipelas;  thus  from  the  suppuration  in 
the  lax  tissue  of  the  interspace  beneath  the  scalp,  the  confined 
pus  may  burrow,  and  in  its  diffusive  march,  destroy  the  nutrient 
vessels  of  the  overlying  parts,  and  cause  the  death  of  parts  so 
deprived  of  blood.  Such  mortification  will  not  be  uniform,  but 
islands  of  dead  tissue  will  be  found  interspersed  in  sections  of 
living  structure.  The  detachment  of  the  sound  from  the 
unsound  parts  in  such  cases  is  very  tedious.  It  need  hardly  be 
remarked  that  such  cases  are  rarer  now  than  formerly;  yet  the 
aseptic  doctrine,  like  all  great  truths,  will  sometimes  fall  short  of 
realization;  and  suppuration  and  erysipelas  will  continue,  as 
hitherto,  to  occupy  some  portion  of  the  domain  of  pathology. 

In  the  cases  of  concealed  suppuration  mentioned,  the  sloughing 
may  be  lessened,  or  prevented,  by  incisions  made  early,  so  as  to 
allow  free  escape  of  the  pus.  In  making  these  incisions  the  vessels 
should  be  studiously  avoided,  for  if  cut,  the  consequent  bleeding 
will  almost  defeat  the  purposes  of  the  opening;  if  an  artery  by 
mischance  should  be  opened,  the  vessels  should  be  ligated.  If 
such  cuts  be  made  in  lines  radiating  from  the  summit  towards 
the  base  of  the  head,  then  the  risk  of  wounding  vessels  will  be 
much  lessened.  Through  the  incisions  made,  the  suppurating 
cavity  should  be  washed  out,  and  the  dressing  completed  by  the 
introduction  of  iodoform  into  the  recesses  of  the  cavity;  thus 
doing,  suppuration  is  lessened  and  healing  is  promoted;  but,  if 


84  WOUNDS    OF    THE    SCALP. 

some  structure  is  lost  through  gangrene,  the  case  should  be  dealt 
with  as  heretofore  detailed. 

Remotely  cognate  to  the  subject  just  treated  of  are  fistula  and 
ulceration. 

A  fistula,  technically  considered,  is  a  tubular  ulcer;  that  is,  a 
canal  of  which  one  or  both  extremities  open  on  the  surface,  and 
the  walls  of  which  are  lined  with  indolent  granulative  tissue.  A 
sero-purulent  fluid  normally  escapes  from  such  a  canal;  and  the 
latter  is  occasionally  so  situated  that  some  excrementitial  matter 
also  escapes  through  it.  The  leadi^ig  characteristic  of  tl)e  fistula 
is  tliat  it  is  non-healing;  in  some  regions  of  the  body  the  fistula 
is  an  unending  source  of  inconvenience  to  its  possessor.  It  does 
not  heal  because  the  materials  which  traverse  it,  separate  the 
canal;  in  some  cases,  also,  the  healing  is  prevented  by  the 
frequent  movement  of  the  structures  in  which  the  fistula  lies; 
but  this  latter  condition  does  not  exist  in  the  case  of  fistula  in  the 
scalp,  and  hence  in  the  treatment  of  fistula  in  that  region,  the 
immobility  is  favorable  to  healing. 

Fistula  of  the  scalp  mav  arise  from  a  phlegmonous  inflam- 
mation, in  which  there  occurs  a  latent  burrowing  in,  or  beneiitli, 
the  structures  of  the  scalp;  the  lost  structure  is  not  whollj 
restored,  and  one  or  more  narrow  ])assages  femain.  Fistula 
may  remain  as  the  sequel  of  scrofulous  or  syphilitic  disease, 
in  which  the  ulceration  penetrates  and  traverses  the  structures, 
and  leaves  unhealing  passages  beneath  the  surface.  And  this 
condition  is  oftenest  found  where  the  bone  is  aftected,  and  being 
in  a  carious  or  necrosed  state,  acts  as  a  foreign  body  at  the  bottoin 
of,  or  along  the  track  of,  the  fistula.  And,  lastly,  a  fistula  has 
arisen  from  the  lodgment  within  the  tissues  of  a  gunshot  missile; 
or  any  other  foreign  object  penetrating  and  remaining  in  the 
scalp  may  leave  an  unhealing  fistulous  canal. 

From  the  diversified  causation  of  fistula  in  the  scalp  (and  the 
same  is  the  case  wherever  it  may  be  found),  some  diagnostic 
acumen  must  be  exercised  to  determine  the  origin  of  it;  whether 
it  be  from  phlegmon,  scrofula,  syphilis,  a  bullet,  or  other  foreign 
body,  will  generally  clearly  appear  from  the  history  of  the  case. 
Besides,  the  sound  is  an  aid  which  should  not  be  neglected;  and 
though  it  may  not  reveal  the  origin,  it  may  reveal  some  important 
conditions  of  the  fistula;  thus,  the  presence  or  absence  of  a  foreign 
body  may  be  determined,  and  especially,  whether  the  subjacent 
bone  is  implicated.  To  distinguish,  however,  between  dead  bone 
and  a  foreign  bodv  is  not  alwavs  easilv  done.     And  even  contact 


ULCERATION.  85 

■with  the  rough  surface  of  sound  bone  has  often  misled  the  searcher. 
Dense  fibrous  or  tendinous  tissue  has  likewise  often  deceived  the 
prober;  great  experience  is  requisite  to  guard  one  from  error  in 
arriving  at  a  correct  diagnosis  in  such  cases. 

The  treatment  of  fistula,  as  may  be  inferred  from  what  has 
preceded,  may  be  wholly  local  in  character,  or  both  local  and 
constitutional.  Where  the  trouble  is  purely  local,  as  from  a 
foreign  body,  then  the  canal  must  be  freely  opened  and  the  body 
removed;  and  this  done,  the  track  of  the  canal  must  be  scraped 
or  curretted,  until  it  has  been  freed  of  its  granulative  investment, 
and  the  work  concluded  by  dressing  with  iodoform  and  means 
before  given.  If,  however,  the  disease  depend  on  cranial  caries 
or  necrosis,  then  the  affected  bone  must  be  wholl}^  removed  by 
gouge  and  chisel,  and  the  further  treatment  correspond  to  that  of 
simple  fistula;  and  if  thus  treated  the  wound  will  close  rapidly. 
But  if  foreign  matter  be  inadvertently  overlooked,  or  some 
diseased  bone  be  left,  the  wound  may  close,  but  reopen  again  in 
a  short  time;  in  such  a  case,  repeat,  and  do  the  work  more 
thoroughly;  especially,  if  the  causal  agency  be  diseased  bone, 
must  the  removal  of  this  be  thorough;  the  excising  chisel  or 
forceps  must  only  cease  work  when  the  instrument  has  passed 
into  the  contiguous  sound  bone;  stopping  short  of  this  has  often 
been  followed  by  a  return  of  the  fistula. 

Should  some  constitutional  disease  coexist,  and  which  must 
be  reckoned  as  the  cause  of  the  fistula,  then  appropriate- treatment 
must  be  directed  to  the  general  disease;  sucli  causal  disease  is 
commonly  scrofula  or  sj^philis;  and  as  the  fistula  present  will  be 
the  same  in  each  case,  the  diagnosis  of  the  causal  affection  must 
be  definitely  made  out  before  appropriate  treatment  can  be  pre- 
scribed. Soon  after  the  constitutional  treatment  has  commenced, 
the  fistula  should  be  operated  on  and  treated  in  the  manner 
■detailed  in  the  preceding  paragraph. 

Ulceration. — By  ulceration  is  meant  that  condition  present 
in  a  part  from  which  the  skin  or  mucous  membrane  has  been 
removed,  and  which  remains  as  an  open  wound,  with  little  or  no 
tendency  to  heal.  Such  wound,  called  an  ulcer,  is  usually 
bounded  by  a  border  regular  in  outline,  and  which  is  elevated 
above  the  ulcerated  surface.  This  surface  is  constituted  of  imper- 
fectly formed  granulative  tissue,  which  has  been  before  referred 
to  as  embryonic  tissue;  and  from  this  surface  is  thrown  off  a  thin, 
pus-like  fluid.  The  discharged  fluid  contains  a  few  pus-cells 
along  with  elements  of  irregular  form,  which  have,  in  part,  arisen 


80  WOUNDS    OF    THE    SCALP. 

from  broken-down,  decomposed  pus  cells.  Some  of  the  formless 
elements  arise  from  tlie  death  and  detachment  of  minute  portions 
of  tiie  ulcerated  tissue.  Ulcers  vary  in  color  from  red  to  a  pale 
hue;  this  depends  on  their  greater  or  lesser  vascularity.  Their 
limiting  margins  also  differ  in  different  cases;  these  may  be  steep 
and  high,  the  margins  may  be  inverted,  and  this  indicates  that 
the  inverted  edge  is  undetermined  by  the  ulcer;  and  this  state  is 
one  unfavorable  to  healing.  When  an  ulcer  is  near  bone,  a  dis- 
eased condition  of  the  bone  ma}-^  be  the  origin  of  the  ulceration. 
Contiguous  vessels,  muscles,  and  nerves  may  also  become  affected. 
The  immediate  cause  of  ulceration  is  a  disturbance  of  the 
vascular  structures  of  the  affected  part;  the  venules,  arterioles,  and 
lymph-vessels  are  in  an  abnormal  state,  the  blood  does  not  come 
to,  and  go  from,  an  ulcerated  part,  as  it  does  in  healthy  structures. 
The  function  of  the  lymphatics  is  likewise  interfered  with;  and 
this  impediment  to  the  movement  of  the  blood  and  lymph  exists 
both  under  an<l  around  the  ulcerated  structure.  In  order  that 
the  nutrition  of  a  part  be  duly  maintained,  the  nutrient  material 
must  be  supplied  to  it  at  regular  intervals,  and  be  under  a  certain 
amount  of  pressure  from  the  action  of  the  heart;  hence  in  the 
process  of  maintenance  of  the  tissues,  several  factors  occur;  and 
without  this  regulated  action  and  concurrence,  the  vital  process 
ceases  and  death  results;  and  when  this  death  is  on  a  large  scale 
the  event  is  gangrene,  but  when  small  particles  or  molecules  only 
die,  it  is  ulceration;  death  in  the  first  ca.se  is  macroscoi)ic,  and  in 
the  second  it  is  microscopic.  In  gangrene  the  obstruction  to 
nutrition  is  primarily  in  the  large  vessels;  but  in  ulceration  the 
impediment  is  in  the  capillaries.  Gangrene  involves  both  the 
superficial  and  the  deeper  structures;  the  action  of  ulceration  is 
limited  to  the  superficial  ones.  Ulceration  does  its  work  in 
detail;  gangrene  does  it  in  mass;  the  former  runs  a  more  chronic 
cour.se  than  gangrene  does.  The  favorite  site  of  the  ulcer  is  on 
the  inferior  extremities,  though  not  infrequently  it  occurs  in  the 
scalp. 

Similar  to  fistula,  ulceration  in  the  scalp  may  be  associated 
with,  or  be  dependent  on,  scrofulous  or  syphilitic  disease.  The 
products  of  these  diseases  interfering  with  the  nutrition  of  the 
parts  adjacent,  often  cause  atrophy  or  even  death  in  these  parts; 
thus  the  tubercular  product  of  .scrofula  and  the  gumma  of  syphilis 
act  destructively  on  parts  adjoining.  The  nature  of  this  accom- 
panying disease  must  be  accurately  determined,  since  the  treat- 
ment of  scrofula  would  be  very  inappropriate  for  syphilis,  and 


ULCER  ATIOX.  87 

vice  versa,  since  the  mercurial  course  so  proper  in  syphilis 
would  be  detrimental  in  scrofula.  Hence  it  is  evident  that  in 
the  treatment  of  ulcer  on  the  scalp,  as  well  as  elsewhere,  the 
varied  causation  must  be  studied. 

When  the  ulcer  is  the  result  of  loss  of  integument  from 
uncomplicated  traumatism,  then  local  means  may  suffice  for 
cure.  The  surface  of  the  ulcer  should  be  carefully  noted,  and  if 
it  be  clad  with  exuberant  granulations,  these  should  be  reduced 
by  an  escharotic.  For  this  an  excellent  agent  is  the  sulphate  of 
zinc,  which  must  be  applied  in  crystal  form.  To  do  this,  cover 
the  part  to  be  acted  on  with  a  stratum  a  half  line  deep  of  the 
crystals  of  the  salt,  cover  these  with  dry  lint  and  allow  them  to 
remain  undisturbed  for  twenty-four  hours:  the  surface  will  then 
be  found  quite  charred  to  a  depth  equal  to  the  thickness  of  the 
stratum  of  the  salt  that  was  used.  This  dead  surface  is  to  be 
removed  by  means  of  a  macerating  cataplasm.  Three  or  four 
days  will  be  required  to  separate  the  destroyed  structure.  The 
surface  tlms  cleared  off  will  heal  rapidly,  the  cicatrization  pro- 
ceeding towards  the  center  from  the  peripheral  border.  If  skin 
grafting  be  resorted  to  at  this  period,  and  a  few  grafts  be  placed 
here  and  thereon  the  raw  surface,  the  healing  will  proceed  much 
more  rapidly  than  if  allowed  to  proceed  wholly  from,  the  circum- 
ference of  the  ulcer;  or  healing  might  be  further  hastened  by  cov- 
ering the  surface  with  epidermal  grafts.  The  healing  will  also 
be  promoted  by  the  local  use  of  a  ten  per  cent  solution  of  alcohol. 
The  secret  of  success  in  the  treatment  of  ulcers  as  well  as  that  of 
many  other  diseases,  local  or  general,  is  not  to  persevere  too  long- 
in  the  use  of  any  one  method.  Nature  is  whimsical  and  requires 
to  be  catered  to  by  variety,  and  hence  when  one  method  ceases  or 
fails  to  do  what  is  wished  of  it,  some  other  means  must  be  resorted 
to.  Change  of  plan  often  accomplishes  what  pertinaceous  conti- 
nuity is  impotent  to  effect. 

As  a  local  application  to  the  ulcer,  iodoform  may  act  well  for 
a  time.  A  better  remedy  than  this  is  the  sub-iodide  of  bismuth. 
This  agent  was  announced  in  1876  as  an  antiseptic  agent.  Dr. 
Reynolds  and  others  reported  good  results  from  its  use;  its  expen- 
siveness  is  an  objection  .to  it.  This  remedy  may  be  employed 
alone  or  combined  with  calomel  or  salicylic  acid;  for  use,  it  is  to 
besprinkled  once  daily  over  the  ulcerated  surface,  and  the  whole 
to  be  protected  by  a  covering  of  adhesive  plaster.  If  the  ulcer  is 
so  situated  as  to  render  the  use  of  the  plaster  difficult,  then  it  may 
be  covered  with  lint  or  a  simple  bandage.     The  author  has  often 


8b  AFFECTIONS    OF    THE    SCALP, 

seen  an  ulcerated  surface  speedily  take  on  a  healthy  character, 
and  cicatrization  to  commence  under  this  management. 

Should  the  prime  causal  factor  be  a  constitutional  disease,  as 
before  stated,  this  should  be  accurately  determined  and  receive 
appropriate  treatment.  As  topical  means,  one  of  the  most  effect- 
ive is  calomel  combined  with  mor[)hia,  in  case  the  patient  has 
constitutional  syphilis.  The  following  is  a  recipe  which,  used 
locally,  has  acted  well: — 

\\.     Hydrargyri  Chloridi  Mitis .^1 

Morphinae  Sulphatis gr.  j 

Misce. 

A  portion  of  such  a  powder  .should  be  sprinkled  over  the  ulcer 
once  daily,  and  the  part  then  covered  with  the  cotton  wadding. 
Meantime  the  patient,  if  feeble,  should  take  internally  the  iodide 
of  potassium  in  combination  with  the  tincture  of  Peruvian  bark. 
Should  the  patient,  however,  be  a  strong  subject,  then  he  may 
take  a  combination  of  mercury  and  iodine;  and  for  this  purpose 
the  protiodide  of  mercury  may  be  given.  As  additional  local 
remedies  may  be  mentioned  the  balsam  of  Peru  and  the  com- 
pound tincture  of  benzoin;  these  remedies  applied  to  ulcerated 
surfaces  stimulate  and  promote  healing.  The  fluid  extract  of 
ergot  may  also  be  used  with  benefit. 

Hypeiirophy. — The  scalp  is  sometimes  the  site  of  abnormal 
thickening;  and  this  hypertrophy  may  embrace  a  large  extent  of 
the  scalp,  or  it  may  be  of  limited  extent.  Such  increase  of 
structure  is  the  result  of  some  prior  derangement  or  disease  of  the 
part.  The  most  usual  cause  is  a  chronic  erysipelatous  inflamma- 
tion of  a  recurrent  or  continuous  form.  In  such  state,  the  affected 
structures,  being  constantly  swollen  with  blood,  receive  an  undue 
quantity  of  formative  material,  and  the  result  is  growth  of  the  part 
beyond  normal  limits.  Such  thickened  structure  is  painless,  and 
except  tliat  it  slightly  deforms  the  head,  it  is  the  cause  of  no 
inconvenience  to  its  possessor;  and  should  this  trouble  be  of 
sufficient  moment  to  cause  the  subject  to  seek  treatment,  the  best 
results  may  be  obtained  from  compression  with  collodion,  and 
also  from  the  topical  use  of  iodine.  And  these  remedies  may  be 
used  in  combination,  viz.,  first  painting  with  tincture  of  iodine 
and  then  cover  the  painted  surface  with  collodion;  thus  the 
absorbent  action  of  the  iodine  and  compression  act  conjointly. 
But  if  the  hypertrophy  be  so  great  as  to  demand  more  active 
measures,  then  the  knife  may  be  resorted  to;  and  wedge-shaped 
portions  having  been  excised,  the  wounds  must  be  closed  with 


ATROPHY.  89 

sutures.  It  is  seldom,  however,  that  a  recourse  to  cutting  will  be 
needed,  or  even  any  other  treatment,  since,  after  a  lapse  of  time,  a 
diminution  of  the  structure  may  confidently  be  anticipated.  For 
it  is  a  rule  that  the  bodily  form,  however  modified  by  circum- 
stance or  contingency,  tends  to  revert  to  the  original  model. 
Careful  of  the  products  of  her  work  during  uncounted  years, 
Nature  jealously  guards  them;  her  maternal  watchfulness  is  ever 
diligent  in  their  maintenance  in  permanent  constancy  in  form 
and  type,  unperverted  and  unchanged;  and  if  changed,  as  a  rule, 
this  is  for  the  better.  The  tendency  to  the  elimination  of  the 
hybrid  or  compound  form  in  the  domain  of  plant  life  finds  its 
analogue  in  animal  life;  the  products  of  cicatrization  and  hyper- 
trophy often  slowly  vanish  and  leave  but  slight  traces  of  their 
existence,  and  such,  in  most  cases,  is  the  final  event  of  hypertrophy 
of  the  scalp  when  due  to  simple  multiplication  of  the  normal 
constituent  elements. 

Atrophy. — An  opposite  condition  to  that  just  considered  is 
atrophy  of  the  scalp,  in  which  it  is  the  subject  of  attenuation,  of 
which  there  are  varying  grades  from  extreme  thinness  to  that 
which  is  scarcely  perceptible.  This  condition  arises  from  imper- 
fect nutrition  of  the  part,  and  in  the  male  is  often  associated  with 
baldness;  and  the  two  are,  doubtless,  promoted  by  the  irrational 
head-dress  which  obstructs  the  circulation  of  blood  in  the  part, 
and  of  the  air  on  its  outside.  The  thinness  of  the  scalp  is  like- 
wise associated  with  attenuation  of  the  adjacent  cranial  wall.  In 
atrophy  of  the  scalp  the  normal  mobility  of  the  part  is  limited, 
or  quite  lost;  and  the  part  so  affected  is  dense,  tense,  and  appar- 
ently bloodless.  The  innervation  of  the  part  is  impaired,  and  in 
every  respect  its  vitality  is  lessened.  Such  tissue,  when  wounded, 
is  slow  to  heal;  and,  on  this  account,  the  surgeon  should  avoid  it 
with  his  knife;  especially  so  when  it  is  the  site  of  atheromatous 
or  sebaceous  tissue,  not  unfrequently  seen  on  the  head  of  old 
persons.  Such  atrophy  is  irremediable,  and  only  exceptionally 
does  it  cause  any  inconvenience. 

Tumors. — By  the  word  "tumor"  was  meant,  primarily,  enlarge- 
ment or  swelling;  including  this  idea,  the  word  has  acquired  in 
pathology  the  additional  meaning  of  a  structure  superadded  to 
some  part  of  the  body,  and  the  superadded  structure  may  resemble 
and  be  nearly  identical  with  the  tissues  in  which  it  is  contained, 
or  from  which  it  arises;  or  the  tissues  which  compose  it,  and  the 
course  which  the  tumor  takes  in  its  development,  may  present 

radical  and  striking  differences  from  the  parent  structure,  whence 
7 


90  AFFECTIONS   OF   THE  SCALP. 

the  tumor  originates.  In  the  former  case,  the  tumor  may  continue 
as  a  harmless  appendage  for  an  indefinite  period,  and  in  many 
cases  causing  its  subject  little  or  no  inconvenience;  if  there  be  any- 
trouble,  this  is  due  to  the  pressure  of  the  tumor  on  adjacent  parts, 
and  also  to  the  deformity  which  it  causes.  The  other  form,  in 
which  the  tumor  consists  of  normal  elements  which  are  abnor- 
mally compounded,  unlike  the  former  type,  sooner  or  later 
becomes  a  source  of  incalculable  trouble.  This  species,  like  any 
organized  being,  has  a  definite  life;  it  starts  from  an  humble, 
usually  unnoticed  origin,  thence  grows  to  such  size  that  the  parts 
on  which  it  rests  are  unable  to  furnish  it  with  sufficient  material 
for  its  maintenance;  it  then  dies,  and  fatally  involves  in  its  death 
tlie  parts  about  it.  Such  tumor,  like  an  ingrate,  finally  ruins  the 
organic  household  into  which,  inadvertently  or  unknowingly,  it 
has  been  adopted.  From  their  action  and  course,  the  former 
group  is  named  benignant  or  benign,  while  the  second  group  is 
named  malignant. 

In  tlie  scalp  almost  all  forms  of  tumors  occur,  both  benign 
and  malignant;  yet  in  our  treatment  of  the  subject  we  will  only 
consider  those  of  greatest  frequency. 

Tumors  originate  from  the  preexistent  constituents  of  the 
parent  tissue,  or  that  in  which  their  growth  is  situated.  In  tlie 
scalp  one  finds  as  component  elements  the  following:  epidermal 
scales,  epithelial  cells,  muscle  of  the  striated  and  non-striated 
species,  connective,  fatty  and  fibrous  tissue,  and  nervous,  vascular 
and  glandular  structures.  Though  seemingly  simple,  the  scalp 
is  a  complex  compound  and  reducible  to  the  proximate  elements 
enumerated;  and  in  any  tumor  growing  in  it,  it  will  be  found 
that  one  element  is  the  sole  or  predominating  constituent,  and 
hence  the  tumor,  elementarily  and  histologically  considered,  is 
simple  in  character;  and  this  is  true  of  both  the  benign  and 
malignant. 

The  benign  type  is  represented  by  the  fibroma,  cystoma, 
lipoma,  and  angioma;  the  representatives  of  the  malignant  type 
are  sarcoma,  epithelioma,  and  carcinoma. 

The  fibroma  is  seldom  seen  in  the  scalp  except  in  the  form  of 
warts;  these,  however,  contain  so  many  elements  besides  fibrous 
tissue  that,  structurally  considered,  they  can  only  be  viewed  as 
remotely  cognate  to  the  fibroma,  which,  in  its  simple  form,  is 
composed  of  fibrous  tissue.  For  the  pure  fibroma  the  scalp  does 
not  furnish  the  conditions  favorable  for  its  development;  space 
for  growth  is  absent     The  nearest  representation  to  it  which  the 


WARTS.  91 

author  has  seen  is  the  fibro-adipose  tumor,  in  which  the  fibrous 
tissue  is  the  chief  constituent.  Such  tumor  occurs  on  the  sides  of 
the  head,  where  the  scalp  is  thickened  by  the  addition  of  fatty, 
muscular  and  tendinous  structure.  The  starting  point  is  gener- 
ally a  scar  resulting  from  a  severe  contusion  or  open  wound. 
And  then  in  the  work  of  repair  the  production  of  granulative 
tissue  is  continued  beyond  what  is  needed  for  restitution  to  normal 
form;  and  in  the  new  growth,  adipose  elements  are  incorporated 
or  entangled,  since  from  the  nature  of  its  development,  such 
growth  is  not  definitely  separated  from  contiguous  parts,  and  the 
tumor  passes  insensibly  into,  and  is  intermingled  with,  neigh- 
boring structures.  Such  growth  is  elevated  above  the  parts 
around,  and  thus  it  becomes  a  slight  deformity  through  inter- 
rupting the  even  surface  of  the  head.  From  its  poverty  in 
nervous  structure  there  is  obtuseness  of  sensibility,  if  such 
structure  be  pricked  or  wounded  in  anyway;  and  yet  through 
encroachment  or  pressure  on  peripheral  nerves,  it  may  become 
the  source  of  pain;  a  neuralgia  or  sensation  of  uneasiness  may 
thus  be  awakened,  and  cause  no  inconsiderable  trouble  to  the 
patient,  so  much  so  that  the  surgeon's  knife  may  be  invoked 
for  relief.  And  should  the  growth  be  painless,  it  should  be 
regarded  with  some  suspicion,  as  it  can  alter  its  type  and  become 
malignant;  in  this  way  sarcoma  and  carcinoma  have  originated. 
Hence,  an  additional  motive  for  the  removal  of  such  fibroma. 
For  this  excision,  let  the  tumor  be  circumscribed  by  a  cut  of  such 
figure  as  to  admit  of  the  readiest  closure  of  the  wound;  and  this 
may  be  elliptical  or  triangular,  for  the  wound  in  either  of  these 
forms  remaining  after  the  removal  of  a  tumor  of  moderate 
dimensions  can  be  closed  by  direct  sliding  or  approximation  of 
the  opposite  edges;  this  should  be  done  with  deep  metallic 
sutures,  which  should  be  allowed  to  remain  in  place  for  not  less 
than  eight  days.  The  wound  should  be  washed  with  alcohol  and 
then  dressed  with  iodoform  and  cotton  wadding.  A  cure  can 
thus  be  accomplished  in  from  ten  to  fourteen  days. 

Warts. — The  wart  is  well  known  as  a  miniature  growth  origi- 
nating in  a  hypertrophy  of  the  papillary  layers  of  the  cutis  of  the 
hands;  the  primary  cause  is  probably  some  continued  local 
irritant,  such  as  the  hands  are  the  subjects  of,  and  also  the  feet 
of  the  barefoot  boy  ;  in  the  latter,  the  feet  being  as  much  exposed 
to  injury  as  are  his  hands,  one  finds  in  him  warts  as  often  on  the 
feet  as  the  hands.  The  Avart  requires  a  free  supply  of  blood,, 
both  for  its  origin  and  subsequent  maintenance;  and  to  this  is 


92  AFFECTIONS    OF    THE   SCALP. 

due  the  occasional  occurrence  of  warts  in  the  scalp.  The  wart 
here  is  concealed  in  the  hair,  and  is  a  source  of  inconvenience  in 
dressing  the  head,  since  in  this  work  it  is  easily  wounded;  and 
from  this  cause,  as  from  being  an  unsightly  object  when  visible, 
its  removal  is  commonly  demanded.  Tliis  may  be  done  by 
escharotics  or  by  excision.  The  escharotic  may  be  applied 
externally,  or  injected  into  the  wart.  Numerous  agents  may  be 
used  for  this  purpose ;  among  the  best  is  nitric,  sulphuric,  car- 
bolic, or  chromic  acid.  Where  the  wart  is  small,  the  local  use  of 
any  of  these  W'ill  accomplish  the  gradual  destruction  of  the 
growth  ;  yet  the  remedy  will  require  to  be  applied  a  number  of 
times,  since  each  application  destroys  but  a  small  portion  of  the 
wart.  Sulphuric  acid  is  l>est  applied  in  the  form  of  a  paste  made 
by  mixing  the  acid  with  powdered  charcoal ;  with  this  mixture 
cover  the  wart  and  let  it  dry,  when  an  adherent  crust  is  formed, 
which  will  fall  off  in  a  few  days,  carrying  a  small  portion  of  the 
wart  with  it.  Instead  of  the  external  use  of  these  acids,  each  one 
may  be  used  by  inserting  or  thrusting  a  drop  of  the  agent  into 
the  wart.  To  do  this,  trim  a  piece  of  oak  or  hickory  wood  into  a 
small,  sharp  point,  and,  having  saturated  the  point  with  nitric  or 
chromic  acid,  thrust  this  through  the  base  of  the  wart.  The 
escharotic  thus  introduced  will  interrupt  the  circulation,  and 
thus  cause  gradual  atrophy  or  immediate  death  of  the  wart. 
Another  method  used  by  the  author  to  destroy  Avarts  is  to  trans- 
fix and  cauterize  it  with  a  long  needle  or  pin  such  as  is  used  in 
the  twisted  suture  in  harelip.  For  this  pur})Ose  take  a  long  cork 
and  thrust  the  pin  through  it  near  one  end,  so  that  the  other  part 
of  the  cork  may  be  used  as  a  holder.  Having  thrust  the  needle 
well  through  the  cork,  next  insert  its  point  in  the  base  of  the 
wart,  and  then  witii  a  small  lamp's  flame  heat  the  needle  on  the 
side  of  the  cork  nearest  the  holder;  in  this  way  the  nutrient 
vessel  of  the  wart  can  be  closed  and  the  wart  caused  to  die  and 
fall  off.  And  finally,  by  the  hypodermic  method,  an  escharotic 
agent  can  be  intfoduced  into  the  base  of  the  wart,  and  its 
destruction  effected;  the  corrosion  of  the  instrument  renders  this 
plan  unsatisfactory. 

The  wart  can  be  very  successfully  destroyed  b}'  directly  ex- 
cising it;  for  this  work  small  curved  scissors  may  be  employed. 
To  remove  the  wart  in  this  way,  let  it  be  transfixed  with  a  tenac- 
ulum so  introduced  as  to  lie  parallel  to,  and  in  the  same  direction 
as,  the  cut  to  be  made;  the  tenaculum  is  next  lifted  up  so  as  to 
elevate  the  wart  above  the  parts  around,  when  the  cutting  can 


CYSTOMA.  93 

readily  be  done  with  the  scissors.  This  excision  will  be  followed 
by  considerable  bleeding,  which,  if  troublesome,  may  be  con- 
trolled by  some  styptic;  for  example,  by  alum  applied  in  solid 
form;  and  where  the  bleeding  is  not  great,  it  is  better  to  allow  it 
to  cease  spontaneously,  as  thus  a  clot  is  formed,  beneath  which 
healing  occurs  rapidly  and  faultlessly,  and  more  conveniently 
than  by  any  other  method,  since  no  dressing  is  needed;  for  the 
encrusted  blood  forms  a  protective  covering  on  the  wound.  This 
plan  of  healing  under  coagulated  blood  may  be  adopted  in  many 
minor  operations  on  the  head  and  face,  and  has  the  advantage 
of  leaving  only  a  slight  scar.  Such  scar  differs  from  that  result- 
ing from  granulation,  in  which  granulative  closure  is  tedious  and 
often  leaves  a  scar,  which  is  unsightly  from  its  unevenness  and 
elevation  above  the  parts  which  surround  it. 

Cystoma. — The  next  form  of  growth  to  be  considered  is  the 
cystoma,  the  generic  name  of  a  large  class  of  benign  tumors,  of 
which  the  leading  characteristics  are  that  they  possess  a  well 
formed  and  clearly  defined  boundary  or  wall ;  and  they  have  a 
content  which  differs  wholly  from  the  containing  wall.  The 
containing  wall  may  be  indistinguishably  fused  with  the  adjacent 
parts,  or  it  may  differ  wholly  from  them  and  be  easily  separable 
from  them.  This  sac,  or  cyst,  as  it  is  ordinarily  named,  is 
usually  wholly  closed,  though  in  a  certain  class  one  can,  by 
inspection,  often  detect  an  opening  in  it.  In  constitution  the 
wall  consists  of  closely  woven  and  compressed  areolar  or  fibrous 
tissue.  In  some  cases  a  thin  filamentous  wall  lies  between  the 
content  and  the  main  wall.  The  main  wall  receives  a  supply  of 
blood  through  one  or  more  vessels  which  enter  it ;  in  some  cases 
the  vessels  are  so  small  that  they  are  hardly  distinguishable  b}^ 
the  eye.  The  arrangement  of  the  arteries  and  veins  is  such  as 
to  retard  rather  than  hasten  the  circulation  of  the  blood  ;  and 
thus  growth  is  favored. 

The  material  contained  in  the  cyst  may  be  synovia,  mucus, 
serum,  sebum,  dermoid  material,  or  blood;  and  such  cysts  are 
named  respectively,  synovial,  mucous,  serous,  sebaceous,  dermoid 
and  blood-cysts.  In  the  case  of  most  cysts  their  origin  can  be 
found  in  the  retention  of  some  secretion  or  excretion,  which  in 
some  way  does  not  have  free  escape  through  its  natural  outlet. 
The  species  of  cysts  found  in  the,  scalp  are  the  serous,  sebaceous, 
dermoid,  and  blood-cyst ;  for  anatomical  reasons,  the  synovial 
and  mucous  cysts  do  not  occur  here. 

The  cyst  of  purely  serous  content  is  infrequent  in  the  scal|) ; 


94  AFFECTIONS    OF    THE    SCAL1>. 

and  ill  most  cases  it  arises  from  extravasation  of  blood  into  the 
tissues,  by  wliich  a  cavity  is  formed  in  which  principally  blood 
is  lodged  ;  the  tissues  immediately  adjacent  undergo  a  change  of 
structure ;  by  condensation  a  wall  is  formed  ;  meantime,  the 
blood  is  absorbed  and  replaced  by  serous  content.  In  otlier  situa- 
tions, as  in  the  case  of  the  scrotal  hydrocele,  the  reverse  may 
occur  ;  serum  may  be  the  original  content,  yet  through  enlarge- 
ment and  rupture  of  vessels  in  the  wall,  blood  may  be  mingled 
with  the  serum.  Besides  this,  the  serum  may  contain  other 
organic  material,  such  as  detritus  cast  off  from  the  wall,  and  also 
material  may  be  precipitated  from  the  serum  itself,  so  that  a 
purely  serous  content  no  longer  exists,  but  instead,  a  turbid 
heterogeneous  fluid. 

The  serous  cyst  in  tiie  scalp  might  be  confounded  with  the 
dermoid  ;  yet  the  briefer  existence  of  the  former,  and  the  history 
of  some  accident,  as  a  contusion,  w'ould  indicate  that  the  tumor 
was  a  serous  and  not  a  dermoid  cyst.  The  dermoid  tumor  is 
nearly  always  found  over  or  near  the  supra-orbital  ridge,  espe- 
cially the  outer  part  of  this  ridge.  The  serous  cyst,  if  it  is  found 
in  there,  lies  more  superficial ;  the  dermoid  growtii  reaches 
deeper  downwards,  and  from  its  subjacent  attachment  to  the 
periosteum  it  admits  of  but  little  lateral  movement.  The  serous 
cyst  may  increase  in  its  volume,  wdiile  the  dermoid  remains  con- 
stant, neither  diminishing  nor  increasing  in  size. 

Unless  the  serous  cyst  be  so  located  on  the  head  as  to  be  a 
visible  deformity,  it  need  not  be  interfered  with  ;  but  should  its 
removal  be  desirable,  tliis  may  be  done  by  compression,  the 
external  use  of  an  absorbent,  or,  finally,  the  work  may  be  done 
more  radically  by  excision. 

Simple  com})ressioii  by  means  of  a  bandage  or  adhesive  plaster, 
continued  for  a  time,  has  caused  such  tumor  to  vanish;  and  the 
same  has  been  done  by  frequently  painting  with  the  tincture  of 
iodine;  and  a  more  effective  agent  of  this  kind  is  iodized  collodion 
prepared  as  follows: — 

Iji.     lodini  puri gr.  vi 

Potassii  lodidi gr-  xij 

Collodii §i 

Misce. 

This  is  to  be  applied  in  the  same  way  as  the  tincture  of  iodine. 
A.  strong  solution  of  muriate  of  ammonia,  viz.,  fifteen  per  cent, 
or  the  pure  powder  of  tliis  salt,  may  be  used.     A  cure  may  like- 


CYSTOMA.  95 

wise  be  obtained  by  injecting  into  the  sack  tincture  of  iodine 
diluted  with  two  parts  of  water.  Such  a  solution  having  been 
injected  is  allowed  to  flow  out  again.  When  done  in  this  manner 
the  cyst  soon  refills,  and  then  absorption  slowly  ensues,  finally 
ending  in  the  cure  of  the  cyst.  Should  an  injection  fail  to  cure, 
the  work  may  be  repeated  after  a  few  weeks.  Lastly,  the  tumor 
may  be  extirpated  by  making  a  straight  incision  through  the 
overlying  integument,  and  then  having  dissected  out  the  sac, 
treat  the  case  as  a  simple  wound. 

Of  all  the  kinds  of  cysts  which  occur  in  the  scalp,  that  of  the 
sebaceous  species  is  the  most  frequent.  This  has  its  origin  in  tlie 
sebaceous  glands,  of  which  one  or  two  are  contiguous  to,  and  open 
into,  each  hair  follicle,  and  have  the  function  of  furnishing  an 
oil-like  matter  to  the  hair.  The  precarious  destiny  of  the  hair 
exposes  its  glandular  satellite  to  frequent  disturbance  and  acci- 
dent; in  the  falling  or  plucking  out  of  the  hair,  the  outlet  of  the 
gland  may  become  closed,  and  still  the  production  of  sebaceous 
material  continues.  The  result  is  distension  of  the  glandular 
cavity  beyond  its  natural  capacity;  and  thus  distended  it  crowds 
on  neighboring  glands  and  involves  these  in  its  morbid  condition. 
The  final  end  is  a  cavity  of  greater  or  less  capacity  filled  with 
abnormal  sebaceous  material,  which,  in  its  changed  condition, 
approaches  more  nearly  to  the  character  of  a  solid  substance  than 
a  licjuid.  Of  the  three  elementary  constituents  of  oil,  viz.,  oleine, 
margarine,  and  stearine,  the  latter  is  the  predominant  one  in  the 
content  of  the  sebaceous  cyst.  When  the  tumor  has  existed  long, 
there  will  be  found  a  countless  number  of  crystals  of  cholesterin 
in  the  content.  Also,  irregular  masses  of  calcareous  matter  are 
likewise  present  in  the  old  cyst.  In  fact,  the  content  having 
lost  its  hold  on  organic  life,  the  processes  of  inorganized  nature 
assume  mastery,  and,  under  the  action  of  crystallization  and  cal- 
cification, the  content  becomes  a  lifeless  fossil.  The  sebaceous 
cyst  presents  a  well-formed  containing  wall  of  wliitish  or  grayish 
color;  and  in  this  sac  a  small  orifice  or  outlet  can  often  be 
detected,  which  continues  through  the  integument;  and  through 
this  opening  the  content  can  be  forced  out — a  procedure  which 
Sir  A.  Cooper  recommends  as  a  method  of  curing  such  cysts. 
Between  the  proper  wall  of  the  cyst  and  that  formed  by  conden- 
sation of  the  tissues  in  which  the  cyst  is  imbedded,  there  exists 
a  thin  stratum  of  filamentous  or  areolar  tissue,  which  contains 
the  nutrient  vessels  prior  to  their  terminating  in  the  proper  cyst- 
wall.  This  intermediate  layer  is  of  such  tenacity  that  it  is  liable 
to  escape  the  attention  of  the  operating  surgeon. 


96  AFFECTIONS    OF    THE    SCALP. 

The  sebaceous  cyst  is  known  among  German  writers  as  the 
atheromatous  cyst,  from  the  resemblance  of  the  content  to  mate- 
rial found  in  the  semi-calcified  tunic  of  the  artery  which  is  the 
site  of  senile  or  fatty  degeneration. 

The  sebaceous  cyst,  in  the  primary  period  of  its  growth,  is  so 
small  that  for  a  time  it  escapes  observation;  it  can,  however,  grow 
to  great  dimensions;  and  in  the  same  scalp  one  finds  sometimes  a 
number  in  different  grades  of  development,  viz.,  from  the  size  of 
a  pea  to  that  of  a  volume  two  or  three  inches  in  diameter.  As  the 
tumor  augments  in  size,  the  overlying  integument  becomes 
thinner,  and  if  this  be  the  site  of  hair,  the  latter  falls. 

From  pressure  or  violence  of  any  kind,  the  cyst  may  inflame 
and  then  its  content  becomes  darker  in  color  and  approaches 
more  nearly  to  a  liquid  in  consistence;  and  such  inflamed  cyst 
tends  to  open  and  discharge  an  ill-smelling,  ichorous  material; 
this  consists  chiefly  of  the  sebaceous  content  which  has  under- 
gone putrefactive  change.  If  unaided  by  art,  such  opened  cyst 
can  continue  discharging  for  several  weeks  or  even  months;  for, 
though  the  content  may  soon  escape,  yet  the  proper  cyst  wall 
only  slowly  disintegrates,  and  during  the  time  that  it  is  breaking 
down  it  probably  continues  its  perverted  excretory  action,  thus 
becoming  a  persistent  source  of  a  discharge  that  is  most  offensive 
in  character.  And  besides  the  offensiveness  of  the  discharged 
material,  the  latter,  not  unfrequently,  through  its  acrid  nature 
attacks  the  structures  with  which  it  comes  in  contact  and  awak- 
ens an  erysipelatous  inflammation,  which  in  its  march  may 
involve  the  scalp  and  face.  This  possible  event  in  the  course  of 
a  sebaceous  cyst  should  be  borne  in  mind,  and  when  it  seems 
impending,  such  unfavorable  event  should  be  forestalled  by  proper 
treatment. 

The  sebaceous  cyst  occurs  in  those  who  have  reached  the 
middle  period  of  life,  probably  from  the  fact  that  the  hair  then 
begins  to  fall,  and  as  a  result  the  hair  follicles  become  obstructed. 
The  commencing  baldness  renders  the  growth  conspicuous  and 
especially  offensive  to  its  possessor.  From  its  volume,  and  espe- 
cially when  multiple,  this  cyst  may  interfere  with  the  head-dress, 
and  on  this  account  the  surgeon's  assistance  is  occasionally  sought. 

For  the  reasons  given,  and  to  rid  the  patient  of  a  deformity, 
the  removal  of  a  sebaceous  cyst  is  a  proper  procedure  unless  the 
patient  be  very  old;  in  all  cases  advanced  age  is  a  most  serious 
contraindication  to  surgical  interference,  and  especially  is  this 
so  in  the  region  of  the  scalp,  wdiere  advancing  years  induce 


CYSTOMA.  97 

attenuation  and  degeneration  of  the  tissues.  In  the  ante-lysterian 
period,  ere  surgery  had  opened  its  eyes  to  the  perils  of  sepsis, 
when  operations  were  often  done  by  the  careless  surgeon  with 
instruments  whose  hilts  and  blades  bore  the  microscopic  remains 
of  a  score  or  two  of  operations,  then  the  old  man  who  submitted 
to  the  removal  of  a  sebaceous  cyst  in  his  scalp,  did  so  at  the  risk 
of  his  life.  The  writer  recalls  the  case  of  an  old  man  in  whom 
the  desire  to  be  rid  of  such  a  deformity  was  paid  for  with  his  life. 
After  these  words  of  caution,  intended  to  emphasize  the  impor- 
tance of  careful  action  in  the  removal  of  the  sebaceous  cyst,  and 
to  give  the  matter  a  place  in  major  rather  than  in  minor  surgery, 
we  will  consider  the  ways  in  which  the  removal  may  best  be 
done;  and  as  methods,  two  have  been  recommended  and  prac- 
ticed, viz.,  one  in  which  there  is  injection  of  some  agent  which 
will  induce  atrophy  of  the  cyst,  and  in  the  other  there  is  imme- 
diate extirpation  of  the  tumor  with  the  knife.  The  absorbent 
or  atrophic  plan  was  announced  by  a  European  surgeon  a  few 
years  ago.  The  medicinal  agent  employed  was  a  strong  solution 
of  tartar  emetic;  in  this  way  it  was  claimed  that  the  sac  was 
caused  to  atrophy,  and  that  the  sebaceous  content  was  reduced  to 
a  calcified  fossil.  It  is  probable  that  this  could  be  done,  but  after- 
wards the  patient  would  not  be  entirely  relieved,  since  an  irreg- 
ular nodule  would  remain  and  disfigure  the  scalp.  This  treat- 
ment is  not  advised  by  the  author,  and  it  is  only  mentioned  here 
as  a  plan  which  might  be  tried  in  those  knife-shy  patients  to 
whom  nature  has  denied  the  endowment  of  courage.  The 
proper  treatment  of  the  sebaceous  cyst  is  to  remove  it  with  the 
scalpel.  As  preliminary  to  this  is  a  careful  preparation  of  the 
part  to  be  operated  on,  which  may  be  done  with  soap  and  w^ater; 
and  when  these  have  been  well  used,  alcohol  should  be  poured 
over  the  part.  To  remove  the  large  cyst  a  portion  of  the  wall 
should  be  excised;  this  excised  portion  should  be  elliptical  in 
outline,  and  should  be  removed  as  the  first  act  in  the  work.  As 
this  part  of  the  investing  dermal  wall  is  thin,  the  operator  runs 
the  risk  in  his  dissection  of  opening  the  underlying  wall  of  the 
cyst,  which  is  likewise  attenuated;  in  fact,  it  is  often  so  thin  and 
tense  that  a  slight  pressure  suffices  to  rupture  it;  and  should  it 
be  opened,  the  remainder  of  the  removal  becomes  much  more 
difficult;  in  fact,  from  the  collapse  of  the  cyst  there  is  danger 
that  some  fragment  of  the  wall  may  be  left,  and  this  will  insure 
a  regrowth  of  the  tumor.  The  integument  covering  the  lateral 
portions  of  the  cyst  is  next  to   be  uplifted  on  each  side,  and 


98  AFFECTIOXS    OF    THE    SCALP. 

retracted  by  means  of  blunt  liooks  or  suitable  retractors;  thus 
held,  the  dissection  can  be  continued  until  the  tumor  is  uplifted  and 
separated  from  its  subjacent  attachments.  The  elliptical  portion 
of  integument,  uhich  is  removed  in  the  case  the  cyst  is  large, 
must  not  be  too  large,  lest  the  gap  made  will  be  so  great  that  it 
cannot  be  easily  closed.  And  should  the  operator  fear  that  he 
cannot  estimate  correctly  the  portion  to  be  excised,  this  work  had 
better  be  deferred  until  the  cyst  has  been  removed,  when  such 
amount  of  the  lateral  valve-like  flaps  can  be  removed  as  will 
permit  of  ])erfect  coaptation  of  the  opposite  edges  of  the  divided 
integument.  Should  the  error  be  committed  of  excising  more 
than  the  superfluous  j)ortion,  then  the  wound  can  only  be  imper- 
fectly closed,  on  account  of  the  absence  of  elasticity  in  the  over- 
lying wall;  for  the  elastic  or  extensile  property  of  the  integu- 
ment which  covers  a  large  sebaceous  cyst  is  gradually  extin- 
guished by  the  constant  pressure  of  the  underlying  growth;  it 
cannot  be  elongated  by  drawing  on  it,  nor  does  it  retract  or 
shorten  to  any  great  extent  after  the  removal  of  the  cyst;  so  that, 
where  a  large  amount  of  the  superfluous  wall  has  been  left,  this 
remains  afterwards  for  a  long  time,  and  perhaps  always,  as  an 
irregularity  in  the  surface.  In  the  work  of  removal,  tlie  vascular 
fllamentous  stratum  which  lies  next  to  the  cyst  must  be  carefullv 
removed;  and  if  any  vessels  bo  opened,  the  bleeding  from  them 
should  be  arrested  by  torsion ;  it  is  seldom  that  ligation  is 
demanded.  Should  torsion  be  insufflcient,  then  exposure  to  the 
air  for  a  few  minutes  will  suffice  to  contract  the  vessels  and  check 
bleeding.  After  washing  the  wound  with  dilute  alcohol,  sprinkle 
with  iodoform  and  then  cover  with  lint;  also  wet  with  dilute 
alcohol.  In  case  the  tumor  be  a  small  one,  as  soon  as  the  cyst 
has  been  removed,  the  covering  integument  falls  into  and  closes 
the  vacant  space;  the  closure  is  so  complete  that  no  pressure, 
suture,  or  tying  of  the  hair  is  required.  But  where  the  tumor  is 
a  large  one  and  the  remaining  valve-like  flaps  do  not  readily 
close  the  breach,  tlien  this  should  be  accomplished  by  the  aid  of 
sutures;  one  or  two  will  be  sufficient;  as  a  rule,  however,  no  arti- 
ficial aid  will  be  needed,  as  the  parts  will,  without  aid,  properly 
adjust  themselves. 

The  case  will  occasionally  offer  itself  for  treatment  in  which 
the  cyst  has,  through  violence  in  some  form,  been  opened,  and 
remains  as  the  source  of  a  constant  foul  discharge;  and  such 
discharge  often  awakens  an  erysipelatous  inflammation  which 
may  be  perilous  to  life.     Operative  interference  is  here  urgently 


lipo:ma.  99 

demanded,  even  though  the  erysipelas  has  commenced  ;  the  cyst 
must  be  freely  opened  and  its  contents  removed  with  the  curette. 
To  check  the  erysipelas,  inject  into  the  infected  structure  a  five 
per  cent  solution  of  carbolic  acid.  This  injection  should  espe- 
cially be  done  in  parts  where  the  disease  is  advancing.  The 
wound  should  then  be  dressed  with  alcohol  and  iodoform.  In- 
stead of  carbolic  acid,  tincture  of  iodine  may  be  injected  into  the 
infected  parts;  as  this  must  be  done  at  several  points,  but  a  drop 
or  two  should  be  inserted  at  each  point.  The  recession  and  van- 
ishing of  the  redness  of  the  affected  structure  is  strikingly  mani- 
fest soon  after  the  injection.  But  where  the  neighboring  parts 
are  yet  intact  around  the  opened  sebaceous  cyst,  the  recovery 
under  proper  treatment  is  usually  unimpeded  and  rapid. 

In  cases  of  multiple  cysts,  one  need  not  hesitate  to  remove  a 
number  at  once,  especially  where  they  are  of  small  volume.  In 
this  work,  if  the  patient  possesses  a  fair  share  of  courage,  the 
work  may  be  done  without  an  ana?sthetic,  since  the  cutting 
through  the  overlying  integument  causes  but  islight  pain.  AVhere 
a  number  of  cysts  exist,  however  careful  the  operator  may  be  in 
his  work,  some  minute  ones  will  probably  not  be  found,  and 
these,  continuing  to  grow,  will  at  some  future  time  demand 
attention. 

As  a  rule  the  sebaceous  cyst  is  met  with  only  in  the  adult  of 
mature  age;  exceptionally,  however,  it  may  occur  at  a  much 
earlier  age.  In  fact,  there  is  sometimes  seen  a  peculiarity  of 
constitution  which  may  be  denominated  a  sebaceous  diathesis,  in 
which  a  great  number  of  these  cysts  appear;  and  these  are  not 
confined  to  the  scalp,  but  they  are  found  on  the  trunk,  and  espe- 
cially on  the  limbs.  The  author  has  seen  instances  of  the  kind 
in  which  there  were  a  great  number  of  such  tumors,  of  different 
sizes,  on  different  parts  of  the  body;  yet  they  were  the  most 
numerous  on  the  scalp.  ISTone  of  the  tumors  reached  a  great 
size;  and  several  of  them  contained  semi-fluid  content  which 
had,  presumably,  arisen  from  some  violence  to  the  cysts.  In  such 
a  case,  in  which  the  cysts  are  so  numerous,  prudence  would  dictate 
abstention  rather  than  surgical  interference;  and  such  interfer- 
ence, if  decided  on,  should  be  limited  to  the  removal  of  such 
tumors  as  give  inconvenience  to  the  subject;  or  to  those  which, 
through  liquefaction,  threaten  to  rupture. 

Lipoma. — The  lipoma  is  a  tumor  of  which  the  predominant 
constituent  is  fatty  tissue;  and  this  may  be  modified  by  the 
addition  of  fibrous  or  vascular  tissue;  and  thence  arise  the  three 
forms  of  pure  lipoma,  fibro-lipoma  and  angio-lipoma. 


100  AFFECTIONS   OF   THE  SCALP. 

Like  the  sebaceous  cyst,  the  lipoma  usually  has  a  proper  wall 
which  closely  invests  the  fatty  tissue;  through  condensation 
of  the  structures  which  contain  the  tumor,  another  wall  is  formed; 
and  these  two  walls  are  separated  by  a  thin  structure  of  web-like 
tissue  in  which  the  nutrient  vessels  lie  previous  to  their  distribu- 
tion to  the  lipoma.  And  this  is  the  usual  disposition  of  the  parts 
in  the  three  classes  mentioned,  viz.,  in  the  pure,  fibrous,  and  vas- 
cular lipoma;  but  there  is  a  form  of  lij)oma  in  Avhich  the  tumor 
is  not  so  separated  from  the  parts  around;  in  fact,  it  is  so  fused 
with  the  contiguous  fatty  structures  that  it  cannot  be  distin- 
guished from  them;  this  form,  named  diffuse  lipoma,  is  embar- 
rassing to  the  operator,  since  he  is  puzzled  to  decide  to  what  point 
the  work  of  removal  should  reach  ;  a  part  may  easily  be  left  from 
which  the  growth  readily  reappears. 

Though  the  lipoma  is  so  easily  recognized  in  most  cases,  yet 
its  diagnosis  is  not  always  an  easy  matter;  indeed,  there  are  few 
surgeons  who  have  not  been  guilty  of  the  error  of  mistaking  a 
lipoma  for  an  abscess,  or  an  abscess  for  a  lipoma.  Such  mistake  is 
commonly  due  to  inadvertance  or  haste,  and  might  be  avoided 
by  attending  to 'the  following  points:  The  lipoma  in  most  cases 
can  be  laterally  displaced,  and  as  this  is  done,  the  covering  skin 
will  be  retracted  so  as  to  ])resent  a  quilted  or  figured  surface;  the 
lipoma  appears  tethered  to  the  integument  at  certain  j)oints,  so 
that  if  the  skin  be  nioved  over  the  tumor,  the  former  is  depressed 
in  regular  lines.  The  abscess  is  more  firmly  imbedded  in  the 
structures,  and  cannot  be  so  readily  moved  as  the  lipoma.  There 
are,  however,  cases  in  which  the  lipoma  and  abscess  are  so  nearly 
alike  that  they  cannot  be  infallibly  distinguished  except  by  the 
use  of  the  exi)loring  needle  of  large  caliber.  A  few  drops  of  the 
pus  of  an  abscess  differ  materially  from  the  adipose  matter  which 
is  withdrawn  from  a  lipoma. 

The  lipoma  when  found  on  the  head  is  oftenest  in  that  part  of 
the  scalp  which  is  adjacent  to,  and  emerges  into,  the  skin  on  the 
back  of  the  neck.  Yet  the  author  has  seen  and  removed  this  tumor 
from  the  region  of  the  frontal  tuberosity;  in  one  case,  the  content 
was  purely  adipose;  in  others  it  was  fibro-adipose.  It  is  oftener 
seen  in  the  strong  and  muscular  subject  and,  from  the  author's 
observation,  oftener  in  the  male  of  short  neck;  and,  in  conse- 
quence of  the  peculiar  conformation  of  the  neck,  the  tumor  may, 
for  a  time,  escape  observation.  In  this  location  the  lipoma  is 
often  of  a  fibrous  type,  and  is  so  hard  and  firm  in  consequence  as 
to  resemble   a  fibroma.      Though  situated   under  the  occipital 


LIPOMA.  101 

portion  of  the  scalp,  this  fibro-lipoma  extends  downwards  on  the 
neck,  so  that  often  it  is  quite  as  much  an  occupant  of  the  neck  as 
of  the  head  ;  and  the  fibrous  character  of  the  tumor  is  also  shared 
by  the  normal  adipose  structures  situated  here. 

The  lipoma  of  the  head,  similar  to  that  in  other  parts  of  the 
body,  is  painless ;  so  that  its  removal  when  undertaken  is  mainly 
done  to  gratify  the  patient,  viz.,  to  relieve  him  of  a  prominence 
which  deforms  the  person  and  interferes  with  the  dress.  In  its 
usual  site  on  the  occipital  cervical  region,  it  may  attain  such  a 
volume  that  it  interferes  with  the  collar  of  the  shirt,  and  causes 
tightness  and  an  unpleasant  constriction;  and  from  the  pressure 
of  the  dress  the  tumor  is  forced  inwards,  reaching,  as  the  author 
has  seen,  quite  down  to  the  upper  cervical  vertebra.  For  these 
reasons  the  extirpation  is  undertaken,  and  should  be  done  before 
the  growth  has  become  very  voluminous.  The  work  is  done  in 
a  manner  similar  to  that  pursued  in  removing  the  sebaceous  cyst; 
yet  it  will  not  be  required  to  excise  any  of  the  covering  integu- 
ment, since  the  superfluous  portion  of  this  will  afterwards  vanish 
through  spontaneous  contraction.  From  the  pressure  to  which 
the  tumor  has  been  subjected  by  the  patient's  dress,  it  will  be 
found  closely  attached  to  the  integument  and  subjacent  parts; 
besides,  the  tumor  is  often  of  the  diffused  species,  that  is,  its 
actual  boundaries  are  indistinguishable.  For  these  reasons  the 
lipoma  here  located,  in  its  removal,  radically  differs  from  that  in 
other  parts  of  the  body;  for  in  other  situations  the  extirpation  of 
the  lipoma  may  be  reckoned  the  easiest  feat  of  the  surgeon's 
knife,  since,  through  one  simple  incision,  the  work  of  enucleation 
can  be  rapidly  done.  But  in  the  case  under  consideration,  the 
work  is  one  of  tedious  dissection. 

After  a  deep  vertical  incision  through  the  thick  and  dense 
skin,  the  work  of  separation  is  to  be  continued  until  the  lateral 
limits  of  the  growth  have  been  reached;  thence  the  work  is  to 
be  continued  downwards  and  underneath  until  the  lipoma  is 
freed  from  the  parts  in  which  it  lies  imbedded.  Usually  one 
or  more  nutrient  arteries  will  be  found  deep  seated,  entering 
the  tumor,  and  which  must  be  ligated ;  if  this  precaution 
be  omitted,  troublesome  bleeding  from  the  wound  will  occur, 
which,  despite  the  closure  and  compression  of  the  wound,  will 
continue;  hence  these  vessels  should  always  be  ligated  or  closed 
by  torsion,  and  thus  the  operator  will  be  saved  the  trouble  of 
subsequently  reopening  the  wound,  and  hunting  for  the  vessels 
amidst  difficulties  which  were  not  present  in  the  primary  work 


102  AFFECnoNS    OF    THE    SCALP. 

of  removal.  Hence,  a  cardinal  rule  to  be  observed  is  to  seek  ond 
tie  all  vessels  as  soon  as  tliey  are  opened.  Even  those  of  minute 
caliber  should  be  controlled,  either  by  torsion  or  tying,  since  they 
are  certain  to  recommence  bleeding,  if  neglected.  The  attempt 
to  prevent  sucli  haMuorrhage  by  the  use  of  a  deep  suture  has, 
doubtless,  disappointed  many  an  operator. 

The  bleeding  being  controlled,  the  surface  of  the  wound  may  be 
sprinkled  with  finely  levigated  iodoform.  This  done,  the  wound 
must  be  closed,  and  this  should  be  done  by  means  of  a  long  curved 
needle;  for  this  one  can  emplo}''  a  handled  needle,  with  its  eye  near 
the  point,  such  as  is  used  for  the  closure  of  the  torn  perineum. 
This  instrument  entering  a  half  inch  from  the  margin  on  one  side, 
is  to  be  passed  down  beneath  the  floor  of  the  wound,  and  then  to 
ascend  and  emerge  at  a  like  distance  from  tlie  edge,  and  the  point 
of  emergence  of  the  suture  should  be  as  nearly  as  possible  opposite 
to  that  of  entrance,  in  order  that  the  apposition  of  the  sides  shall 
correspond  to  their  normal  position  and  situation  before  they  were 
opened.  But  if  the  wound  have  much  depth,  as  it  may  have  in 
the  robust  subject,  then  there  may  be  dithculty  in  obtaining 
exact  apposition  of  the  wound's  walls.  Where  these  conditions 
are  present,  by  a  plan  used  by  the  author,  better  coaptation  can 
be  gotten  than  is  obtained  by  the  common  suture;  this,  which 
may  be  named  the  figure-of-eight  suture,  is  to  be  introduced  as 
follows:  A  needle  of  semicircular  curve  is  to  be  threaded  with 
aseptic  silken  thread,  or  flexible  wire,  and,  being  introduced  into 
one  wall  of  the  wound  at  the  middle  point  of  its  depth,  the  needle 
is  carried  downwards  beneatli  the  wound,  and  let  emerge  at  tlie 
corresponding  middle  point  of  the  opposite  side;  from  this  point 
tlie  needle  is  carried  and  made  to  enter  the  point  of  commence- 
ment, and  brought  thence  through  the  remainder  of  the  wall, 
emerging  through  the  skin  a  short  distance  from  the  edge  of  the 
opening;  next  the  remaining  loose  end  of  the  thread  is  to  be 
armed  with  a  needle  and  carried  across  and  caused  to  pass  through 
the  remaining  unincluded  portion  of  the  wall  of  the  wound. 
The  work  thus  described  in  words,  like  all  descriptions  of  mechan- 
ical work,  is  not  very  clear,  as  Hippocrates  remarks  in  his 
description  of  mechanism  for  dressing  fractures;  yet  it  is  readily 
comprehended  when  it  is  stated  that  when  closed  the  suture 
represents  a  figure  of  eight,  of  which  the  deeper  portion  is  first 
introduced.  When  such  a  suture  is  closed,  it  cannot  fiiil  to  bring 
the  walls  of  the  wound  into  apposition  throughout  their  entire 
extent;  no  space  is  left  in  which   blood  or  other  material  can 


ANGIOMA.  103 

collect — a  condition  most  necessary  to  obtain  speedy  nnion. 
This  suture  does  not  cramp  the  included  structures  into  a  circular 
form  as  the  usual  suture  does.  And  it  can  be  removed  as  readily 
when  its  work  is  done  as  the  usual  suture.  The  use  of  this  suture, 
it  need  scarcely  be  mentioned,  is  applicable  in  the  scalp  only  in 
the  inferior  part  of  the  occipital  region,  since  elsewhere  the 
structures  are  not  thick  enough  to  demand  its  use. 

Angioma.. — By  this  term  is  meant  a  tumor  of  which  the  pre- 
dominant constituent  is  vascular  tissue;  and  these  vessels  are  of 
different  thickness,  viz.,  they  may  vary  from  that  of  minute 
caliber,  so  small  as  to  be  unseen  by  the  unaided  eye,  to  that  of 
vessels  of  considerable  caliber.  The  angioma  is  capable  of  be- 
coming turgid;  and  this  property  of  temporarily  swelling  has 
given  the  angioma  a  place  among  the  erectile  structures  of  the 
body;  yet  it  differs  materially  from  those  structures  of  which 
erection  is  a  normal  and  physiological  action;  the  turgid  state 
occasionally  occurring  in  the  angioma  is  an  accidental  condition 
dependent  on  the  circumstance,  that  blood  under  some  movement 
of  the  body  is  forced  from  the  heart  towards  the  periphery;  and 
this  action  is,  in  most  cases,  some  phase  of  expiration,  as  in  the 
acts  of  coughing,  crying,  screaming,  and  straining,  acts  in  which 
the  blood  is  forced  towards  the  periphery  and  temporarily 
retained  there.  Hence  these  structures  are  not  properly  erectile, 
but  through  some  contingency  they  become  swollen.  The  prop- 
erty mentioned  is  often  connected  with  the  growth  of  the 
angioma.  The  angioma  may  consist  of  fine  capillaries,  or  of  large 
vessels  which  are  remarkable  for  their  involved  and  contorted 
disposition;  and  these  vessels  present  irregular  dilatation,  which 
are  called  caverns;  hence  the  two  species  of  angioma  have  been 
respectively  named  capillary  and  cavernous. 

The  capillary  angioma  may  vary  in  size  from  a  mere  point  to 
that  of  a  large  surface;  and  it  may  be  superficial  or  penetrate 
deeply.  The  caliber  of  the  constituent  vessels  have  an  influence 
on  these  conditions.  The  most  superficial  variety  is  the  red-wine 
mark,  which  arises  from  a  dilatation  and  multiplication  of  the 
outermost  dermal  capillaries.  Between  the  superficial  species  and 
the  cavernous  angioma,  in  which  the  vessels  are  dilated  into 
irregular  sacs,  there  are  numerous  gradations;  as  the  develop- 
ment reaches  inwards,  the  vessels  are  found  more  dilated  and  of 
greater  caliber;  the  vessels  reach  such  dimensions  in  the  caver- 
nous species  that  the  pulsating  arteries  impart  an  impulse  to  the 
hand  akin  to  that  of  an  aneurism.     AVhen  constituted  of  larger 


104  AFFECTIONS   OF   THE   SCALP. 

vessels,  the  intervascular  tissue  increases  in  amount  so  that  the 
normal  volume  of  the  affected  part  is  more  or  less  hypertrophied. 

The  color  of  the  angioma  varies  from  the  bright  red  hue  of 
the  superficial  wine-color  mark,  to  that  which  does  not  differ  from 
the  normal  hue  of  the  skin.  The  color  of  the  deep-seated  species 
is  often  blue,  and  has  given  rise  to  the  opinion  that  such  growth 
is  composed  chiefly  of  veins;  if,  however,  such  angioma  be  pricked, 
the  blood  which  oozes  thence  will  be  found  to  be  bright  red  and 
plainly  of  arterial  character.  The  color,  though  varying,  is  of 
valuable  diagnostic  import;  yet  this  sign  is  not  infallible,  since 
the  cyst  of  liquid  content  may  also  contain  blood,  which,  permeat- 
ing the  wall  of  the  cyst,  gives  the  semblance  of  an  angioma.  The 
ordinary  angioma  is  usually  painless,  and  the  subject  would  be 
unconscious  of  its  presence  if  he  did  not  see  or  touch  it;  this,  how- 
ever, is  not  always  true,  since  the  angioma  may  cause  much  dis- 
comfort, and  even  acute  pain,  when  it  is  large  and  presses  on 
nerves. 

The  history  of  an  angioma  is  usually  an  indefinite  one;  as  a 
rule  it  is  coeval  with  birth,  having  originated  in  embryonic  life; 
yet  there  area  few  exceptions  to  congenital  origin.  When  congeni- 
tal, its  origin  has  been  associated  with  some  error  in  the  develop- 
ment of  the  primordial  segments  of  the  early  embryo;  others, 
discarding  this  theory,  refer  the  origin  of  the  angioma  to  some 
accidentoccurring  in  intra-uterineor post-uterine  life.  Angiomata 
having  arisen  often  follow  divergent  lines  in  their  subsequent 
course;  one  retains  its  i)rimitive  form  and  character  without  much 
change;  another  grows  slowly  or  very  rapidly,  and,  having  reached 
certain  dimensions,  ceases  to  grow  and,  later,  it  may  increase  in 
size.  The  tumor,  when  it  follows  a  course  of  unlimited  growth, 
may  press  on  and  destroy  bones,  muscles,  nerves,  etc.;  in  fact, 
destroy  or  render  the  affected  part  wholly  functionless.  And 
finally,  in  another  class  of  cases  of  congenital  origin,  during 
infantile  growth,  it  sometimes  fortunately  occurs  that  the  angi- 
omatous structure  atrophies,  and,  finally,  nearly  or  entirely  disap- 
pears; this  desirable  event  is  seen  now  and  then  in  the  superfi- 
cial dermal  form;  the  infant  loses  the  deformity,  greatly  to  the 
delight  of  the  mother,  who  suspects  that  she  is  guilty  of  marking 
her  child.  The  belief  in  such  origin  is  deeply  rooted  in  the  popu- 
lar mind,  in  which  so  many  errors  planted  in  the  past  have  taken 
fast  hold;  to  pluck  thence  the  present  one,  which  lives  in  the 
name  nseims  mafernvs,  or  mother's  mark,  will  demand  a  long 
period  in  future  time.     And  the  prospect  of  its  eradication  is 


ANGIOMA.  105 

narrowed,  when  the  fact  is  recalled  that  this  error  is  shared  by 
some  minds  otherwise  noble  in  our  profession.  The  author 
heard  a  clinical  lecture  some  years  ago  in  which  a  famous  Euro- 
pean surgeon  c[uite  failed  to  show  his  disbelief  in  regard  to 
maternal  agency  in  the  causation  of  dermal  angioma;  indeed, 
the  cases  which  he  enumerated,  in  which  these  stigmata  might  be 
referred  to  the  fear,  fright,  or  fancy  of  the  mother,  were  so  pointed 
that  it  was  clear  that  the  would-be  skeptic  was  a  partial  believer. 
The  speaker  forgot  to  call  the  attention  of  his  hearers  to  the  host 
of  uncounted  exceptions  in  this  field,  w^here  "millions  miss  for  one 
that  hits."  Beliefs  of  the  kind  here  cited  are  often  so  fondly 
nursed,  especially  by  the  great  multitude  that  finds  it  awkward 
and  irksome  to  think  outside  of  wonted  lines,  that  he  who  would 
eliminate  them  is  seldom  complacently  listened  to. 

The  marked  characteristics  of  angioma,  especially  that  of 
purely  dermal  site,  is  its  want  of  circumscription;  no  definite 
boundary  isolates  it  from  adjacent  parts,  and  the  lack  of  such 
limiting  bounds  favors  its  extension  into  contiguous  parts;  there 
are,  however,  exceptions  to  this  diffusion,  viz.,  the  growth  may 
be  capsulated  so  as  to  resemble  a  cyst.  In  these  exceptional  cases 
the  containing  wall  is  closely  adherent  to  the  vascular  structure; 
in  fact,  it  cannot,  without  violent  dissection,  be  separated  from  the 
vascular  structure;  on  the  contrary,  this  quasi  cyst  is  loosely  con- 
nected to  the  parts  which  contain  it,  since  there  only  intervenes 
between  the  two  a  loose,  filamentous  tissue. 

As  has  been  stated,  the  angioma  can  spontaneously  vanish 
and  leave  no  trace  of  its  previous  existence;  besides  this  most 
desirable  ending,  other  changes  may  occur  which  deserve  mention. 
For  example,  in  one  of  these,  from  structural  changes  which 
occur  in  the  angioma,  the  supply  of  blood  may  be  interrupted 
and  the  remaining  spaces  or  vacuoles  in  the  tumor  remain,  and 
the  separating  partitions  vanishing,  there  finally  is  left  a  common 
cavity,  similar  to  a  serous  cyst.  A  deviation  from  this  form  is 
that  in  which  the  liquid  content  of  the  cavity  is  absorbed,  and 
there  only  remains  some  solid  material.  These  altered  forms  of 
angioma  have  resulted  from  some  of  the  modes  of  treatment 
resorted  to  for  the  cure  of  the'tumor. 

The  diagnosis  of  the  dermal  angioma  is  easily  made  where  the 
growth  is  superficial;  its  congenital  origin,  red  hue,  temperature 
above  that  of  the  parts  around,  and  capability  of  becoming  turgid 
from  an  expiratory  or  straining  effort  of  the  child,  are   marks 

which   clearly  distinguish    such   growth    from   other   abnormal 

•   8 


106  AFFECTIONS    OF    THE    SCALP. 

developments.  When  more  deeply  seated,  the  livid  color,  tur- 
gescence,  and  warmth  are  characteristic  features;  and  should  tliere 
be  doubt  as  to  its  nature,  the  rapid  bleeding  that  would  follow  a 
prick  or  slight  incision,  would  clearly  indicate  an  angioma. 

From  numerical  observation  it  has  been  found  that  the  dermal 
angioma  is  found  on  the  head  much  oftener  than  elsewhere,  viz., 
two-thirds  of  the  cases  observed  were  on  the  head.  Some  occur 
on  the  hairy  scalp,  yet  the  larger  number  have  their  site  on  the 
forehead  and  face. 

The  surgeon's  aid  is  often  invoked  for  the  relief  of  the  angi- 
oma; especially,  when  it  is  congenital,  there  is  usually  an  urgent 
desire  on  the  part  of  the  infant's  parent  to  have  the  marring  part 
removed.  And  even  the  adult  who  has  inertly  and  complacently 
borne,  for  years,  a  red,  purple,  or  wine  mark,  some  day  may  be 
seized  with  an  irresistible  impulse  to  be  freed  of  his  deformity,  his 
chief  reason  perhaps  being  that  he  desires  to  "look  like  his 
friends."  Such  an  impulse  once  awakened  is  similar  to  all 
ungratified  whims,  it  never  vanishes  until  its  purpose  has  been 
realized. 

In  most  cases  the  dermal  angioma  is  painless;  and  its  re- 
moval is  only  desired  in  order  to  be  rid  of  a  disfiguring  mark; 
and,  as  this  is  the  principal  thing  sought,  the  surgeon's  task  is 
surrounded  with  unusual  difficulties;  for  in  no  way  can  such 
work  be  accomplished  without  leaving  some  cicatricial  evidence 
of  what  has  been  done;  some  scar  must  inevitably  remain  ;  and 
this  often  becomes  to  the  patient  quite  as  offensive  as  was  the 
angioma;  but  as  the  latter  has  vanished  from  view,  it  is  quickly 
forgotten,  while  the  cicatrix  remains  and  becomes  an  ever-during, 
hated  object.  The  footsteps  of  time  are  constantly  changing  the 
human  face;  and,  though  they  may  obliterate  some  of  the  un- 
sightliness  of  a  cicatrix,  yet  the  latter  can  never  be  wholly 
effaced  ;  and  in  it,  as  in  an  ind'elible  inscrpition,  the  imperfec- 
tions of  the  surgeon's  art  ever  legibly  appear. 

Instead  of  commencing  his  work  at  once,  the  prudent  surgeon 
will  premise  his  treatment  with  certain  23reliminaries  intended 
to  prepare  the  patient's  mind,  or  that  of  the  friends,  for  the  future 
condition  of  the  part  ojx'rated  on;  tlie  scarring  which  must  result 
from  the  operation  must  be  heralded  in  emphatic  terms;  and 
should  this  be  strongly  deprecated  by  the  patient,  then  it  is  far 
better  that  no  operative  procedure  be  attempted  than  that  the 
surgeon  should  plant  in  the  patient's  heart  a  feeling  of  unend- 
ing resentment  against  him.     In  cases  involving  life,  such  pre- 


ANGIOMA,  107 

cautionary  policy  and  prophylactic  conservatism  on  the  part  of 
thp  surgeon  should  be  allowed  no  place  in  his  action ;  but  in  the 
case  under  consideration,  in  which  the  patient's  life,  comfort,  and 
ease  are  not  interested,  and  the  removal  of  the  deformity  will  not 
remove  a  pain,  nor  add  one  day  of  life,  and  where  the  proposed 
work  is  one  of  "complacency,"  then  to  such  prudential  considera- 
tion prominent  place  should  be  given.  The  clear-minded  Celsus 
duly  estimated  such  discretion  where  he  refers  to  the  hesitancy 
of  the  physician  to  adopt  treatment  of  doubtful  result  in  a 
"  splendid  personage." 

The  patient  having  consented  to  accept  the  results  of  scarring, 
which  may  never  vanish  from  sight,  the  surgeon  proceeds  to 
select  one  of  the  many  methods  which  may  be  chosen  for  the 
removal  of  an  angioma;  the  principal  ones  of  these  methods  are 
excision,  ligation,  cauterization  (actual  and  potential),  the  induc- 
tion of  coagulation  of  the  blood  of  the  growth,  destruction  by 
vaccination,  and  induction  of  atrophy  by  compression. 

Of  the  methods  mentioned,  the  author  has  a  decided  prefer- 
ence for  excision,  based  on  an  extended  use  of  the  same;  yet  the 
beginner  may  be  wanting  in  some  of  the  requisites  needed  to  do 
the  work  in  this  way.  The  peril  in  this  method  is  from  the  loss 
of  blood ;  to  lessen  this  loss,  the  excision  must  be  done  rapidly 
and  the  vessels  secured  quickly — work  which  is  best  done  by  one 
who  has  had  ample  discipline  in  operative  work.  The  advan- 
tages which  the  method  of  excision  has  are  that  it  reduces 
scarring  to  the  minimum  amount;  and  it  reduces  the  period  of 
healing  to  its  shortest  limits.  To  operate  by  excision  one  must 
have  two  assistants,  and,  as  instruments,  scalpel,  curved  needles 
armed  with  wire,  scissors,  haemostatic  forceps,  and  silk  ligature. 
The  silk  ligature  is  rarely  needed,  yet  it  should  be  at  hand.  To 
one  assistant  should  be  committed  the  important  task  of  making- 
compression  around  the  part  to  be  removed,  and  also  on  the 
carotid  artery  which  furnishes  blood  to  the  tumor;  for  the  latter 
compression,  a  third  assistant  may  be  required.  Inattention  to 
these  means  of  preventing  the  loss  of  blood  has  been  the  cause 
of  death  in  several  recorded  cases.  The  temporary  compression 
of  the  carotid  artery  is  an  important  precaution,  where  the  growth 
is  unilateral  in  site,  as  thus  the  bleeding  may  be  controlled  in  a 
great  measure. 

The  cutting  may  be  done  quickly  or  slowly ;  in  the  first  way 
the  growth  is  removed  as  rapidly  as  possible,  the  vessels  being 
secured  after  the  removal ;  but  in  the  second  way,  the  vessels  are 


108  AFFECTIONS    OF    THE   SCALP. 

secured  as  they  are  divided.  As  Petit  advised,  the  line  of  incision 
should  be  in  the  boundary  between  the  sound  and  the  affected  struc- 
tures; done  thus,  the  haemorrhage  will  be  reduced  to  the  smallest 
amount.  AVhere  the  angioma  is  of  small  dimensions,  it  may  be 
easily  and  safely  removed  by  the  rapid  plan ;  when  thus  done, 
the  assistant  who  is  compressing  the  parts  around,  lessens  the 
wound  by  sliding  its  borders  towards  each  other;  and  when  thus 
approximated,  tlie  edges,  through  the  aid  of  the  sutures,  can  be 
brought  quite  together,  provided  the  angioma  is  of  small  extent. 
The  sutures  should  be  introduced  so  as  to  include  the  vessels, 
and  thus  the  bleeding  is  controlled.  In  introducing  the  suture, 
the  needle  must  avoid  the  vessels;  and  if  these  be  tranfixed, 
which  will  be  revealed  by  blood  escaping  from  the  wounds  made 
by  the  needle,  then  the  needle  should  be  withdrawn  and  passed 
at  another  point.  A  suture  transfixing  a  vessel  not  only  causes 
bleeding  externally,  but  it  may  do  so  internally,  beneath  the 
scalp.  Haemorrhage  under  the  scalp  may  occur  where  an  edge 
containing  a  vessel  is  infolded,  and  such  bleeding,  being  con- 
cealed, may  be  so  great  as  to  be  dangerous.  This  concealed 
bleeding  may  occur  in  operating  in  other  parts  of  the  body  in 
which  wounds  are  closed  externally,  while  vessels  are  left  open, 
and  bleeding  continues  in  the  wound  beneath.  In  such  cases  the 
blood  continues  escaping  and  fills  every  recess  of  the  wound ; 
and  the  clotting  blood,  wedge-like,  thus  insinuates  itself  between 
the  opposite  walls  of  the  wound  or  cavity,  and  prevents  healing. 
And  in  the  wound  caused  by  removing  the  angioma  from  the 
child's  scalp,  such  concealed  haemorrhage  is  very  perilous,  since 
in  the  loose  interspace  between  the  nericranium  and  the  hairy  scalp 
the  blood  has  room  to  collect  in  large  amount;  enough,  in  fact, 
to  cause  death,  as  occurred  in  a  case  reported  some  years  ago. 
In  this  unfortunate  case  the  angioma  was  excised  from  the 
frontal  region,  the  wound  closed  by  suture,  yet  the  blood  con- 
tinued to  flow  unperceived,  until  the  infant  perished,  when  it  was 
discovered  that  an  immense  quantity  of  blood  was  imprisoned  in 
the  space  referred  to.  Hence  in  excising  the  angioma  from  the 
scalp,  the  operator  should  neglect  no  precaution  to  avoid  both 
seen  and  unseen  haemorrhage. 

If  the  angioma  be  of  large  extent,  then  the  slow  method  of 
dividing  section  by  section  is  the  safer  plan;  then  the  vessels  can 
be  ligated  as  soon  as  they  are  severed.  Another  method  is  by 
percutaneous  transfixion,  in  which  one  so  circumscribes  the 
vessels  beyond  the  line  of  cutting  that  the  incision  can  be  made 


ANGIOMA.  109 

in  nearly  bloodless  tissue.  This  hgemostatic  precaution  being 
taken,  the  excision  is  next  to  be  done,  and  the  vessels  ligated  as 
they  are  opened.  Or  should  the  provisional  circumscription  be 
so  complete  as  to  quite  control  any  bleeding  from  the  wounded 
vessels,  then  the  ligation  of  the  latter  may  be  dispensed  with, 
and  the  circumscribing  ligatures  be  left  in  site  for  three  days, 
when  they  can  be  removed.  Meantime,  an  attempt  should  be 
made  to  close  the  wound  as  nearly  as  possible.  This  is  best  done 
by  metallic  sutures  which  are  introduced  a  little  distance  from 
the  margin,"  so  that  some  traction  can  be  made  with  them. 
Where  the  breach  made  is  very  extensive,  and  the  closure  by 
direct  apposition  is  impossible,  then  the  work  may  be  done 
plastically  by  dissecting  up  flaps  from  the  contiguous  scalp,  and 
turning  these  into  the  opening ;  thus  complete  closure  can  some- 
times be  accomplished ;  or  if  it  be  not  complete,  then  the  small 
spaces  left  uncovered  will  soon  heal  by  cicatrization. 

The  infantile  angioma  has  been  removed  by  ligation;  and  the 
work  can  be  done  in  sections;  or  the  growth  may  be  tied  in  one 
mass.  If  ligation  be  attempted,  the  plan  of  doing  this  in  mass  is 
the  better  one;  for  when  done  in  sections,  some  of  the  structure 
may  not  be  included,  and  through  this  the  vitality  of  the  growth 
may  be  maintained,  and  thus  a  failure  result.  Ligation  in  mass 
is  best  done  subcutaneously.  To  do  this,  let  a  well-curved  needle 
armed  with  a  strong  silken  thread  enter  at  some  point  on  the 
border  of  the  angioma,  and,  passing  some  distance  under  the  skin, 
emerge  at  another  point  in  the  border  of  the  growth;  let  the 
needle  reenter  and  emerge  again;  and  thus  let  the  work  proceed 
until  the  needle  has  passed  quite  around  the  growth,  and  emerge 
at  the  first  point  of  entrance.  When  it  is  thus  done,  the  silken 
thread  will  have  encircled  the  tumor,  and  the  two  ends  of  the 
ligature  having  been  tied  firmly  together,  the  growth  will  be  cut 
off  from  its  supply  of  blood,  and  die  from  strangulation.  The 
cord  should  be  so  tied  that  it  can  be  retied  as  soon  as  it  loosens. 
This  method  has  been  successfully  used  by  the  author,  yet  there 
is  an  objection  to  it  in  this,  that  it  is  attended  by  suppuration, 
and,  there  being  no  free  outlet  for  the  pus,  it  may  have  a  septic 
action.  Yet  in  a  large  erectile  tumor  in  an  infant's  face,  the 
author  obtained  a  satisfactory  result;  the  scarring  was  not  un- 
sightly, since  the  skin  remained  intact  except  where  the  needle 
wounded  the  parts.  Where  the  tying  is  done  in  sections,  the  skin 
being  included,  the  skin  must  necessarily  die,  and  thus  the  scar- 
ring is  greater  than  when  the  work  is  done  by  subcutaneous 


110  AFFECTIONS    OF    THE    SCALP. 

circumscription.  The  plan  of  ligating  by  means  of  a  ligature 
thrown  around  transfixing  needles  has  been  tried;  this  method 
is  less  effectual  than  the  other  modes  of  ligation  which  have  been 
described.  Also,  temporary  ligation,  in  which  the  ligature  is 
removed  after  a  couple  of  days,  has  not  given  satisfactory  results; 
for  the  part  that  has  thus  been  deprived  of  blood  is  rapidly 
resuscitated  after  the  removal  of  the  ligature. 

Cauterization,  actual  and  potential,  has  been  employed  for  the 
removal  of  angioma.  AVhen  the  growth  is  superficial,  it  may  be 
removed  by  touching  it  with  a  cauterizing  iron  t^hat  has  been 
heated  only  to  brown  heat;  at  such  a  temperature  the  work  can 
be  done  without  breaking  the  surface  acted  on.  Sucli  a  heat  will 
coagulate  the  albuminoid  content  of  the  blood,  and  thus  an 
im})ortant  step  is  taken  towards  lessening  the  nutrition  of  the 
angioma.  This  cauterization  should  be  repeated  once  in  forty- 
eight  hours;  and  if  persevered  in,  a  superficial  angioma  may 
thus  be  removed.  A  degree  of  heat  sufficient  to  do  the  work  can 
be  obtained  by  immersing  the  cauterizing  iron  in  boiling  water. 
But  in  case  the  growth  be  thicker  and  approach  to  the  cavernous 
tyi)e,  then  superficial  cauterization  will  l)e  insufficient;  in  sucli 
case  the  work  can  be  done  by  means  of  a  needle  at  red  heat,  that 
is  inserted  into  the  tumor.  This  can  be  done  in  the  manner 
described  for  the  destruction  of  warts,  in  which  a  long  needle 
having  been  made  to  penetrate,  the  latter  is  afterwards  heated  to 
a  red  heat.  The  needle  must  be  made  to  enter  different  parts  of 
the  growth  at  intervals  of  a  quarter  of  an  inch ;  thus  done,  the 
clotted  blood  interrupts  the  circulation,  and,  checking  the  nutri- 
tion of  the  growth,  the  latter  is  caused  to  atrophy.  In  the 
author's  essays  with  this  plan  he  found  that  there  was  less  danger 
of  wholly  destroying  the  growth  by  excessive  heat  than  he  appre- 
hended; even  though  the  angiomatous  structure  was  pierced  and 
burned  at  many  points,  yet  it  soon  regained  its  vitality,  so  that  it 
became  necessary  to  repeat  the  cauterization  two  or  three  times, 
at  intervals  of  a  week  or  two.  Done  in  this  manner,  the  skin  is 
not  destroyed,  but  the  subjacent  vascular  structure  atrophies,  and 
the  affected  part  gradually  approaches  the  type  of  the  contiguous 
sound  parts;  some  months,  however,  will  be  needed  to  finally 
complete  this  reduction.  Besides  the  plans  described,  the  cauter- 
ization may  be  done  by  means  of  the  thermal  cautery;  for  this  a 
special  apparatus  is  required,  while  for  the  method  above  described, 
some  simple  means  may  easily  be  contrived. 

The  dermal  angioma  may  be  removed  by  the  potential  cautery. 


AXGIOilA.  Ill 

For  this  purpose,  when  the  growth  is  superficial,  nitric  acid  may 
be  used ;  to  do  this,  let  a  glass  rod  be  dipped  into  the  fuming  acid 
and  applied  to  the  surface  of  the  angioma.  This  repeated  daily 
for  a  number  of  times,  by  coagulating  the  blood  in  the  superficial 
vessels,  ends  in  causing  atrophy  of  the  vascular  growth.  It  is 
only  in  cases  in  which  the  growth  is  very  superficial  that  this 
plan  is  successful.  This  treatment  was  much  employed  by 
Langenbeck,  yet  in  trials  of  it  by  the  author,  the  results  have 
not  been  satisfactory.  It  might,  however,  be  tried  in  cases  in 
which  the  angioma  is  merely  superficial;  but  when  the  growth 
comprises  the  entire  thickness  of  the  skin,  then  cauterization  done 
potentially  rec[uires  a  more  active  agent  than  nitric  acid;  as  such 
are  chloride  of  zinc  and  caustic  potash;  arsenic,  also,  has  been 
used,  yet  its  poisonous  property  renders  its  use  unsafe.  To  use 
chloride  of  zinc,  let  the  following  mixture  of  it  be  made: — 

^.     Zinci  Chloridi. 

Farinse aa  3i 

Misce. 

This  moistened  into  a  paste  may  be  spread  over  the 
growth,  when  it  hardens  into  a  crust-like  coat.  In  this  way 
a  stratum  of  the  angioma  is  destroyed,  and,  after  a  few  days, 
it  will  fall  off  as  a  dry  eschar.  After  this  detachment,  the 
escharotic  paste  may  be  applied  again,  and  this  work  may  be 
repeated  until  the  growth  is  wholly  removed.  This  is  one  of  the 
safest  plans  of  potential  cauterization ;  yet  the  work  is  painful 
and  tedious.  The  work,  however,  may  be  more  rapidly  done  by 
means  of  potassa  fusa;  but  the  caustic  potash  is  too  violent  in 
action  if  used  in  its  pure  state,  and,  hence,  it  should  be  employed 
in  a  dilute  form ;  for  this  it  may  be  mixed  with  an  equal  part  of 
Pulvis  Radicis  Sanguinariee,  or  with  an  equal  part  of  calcined 
magnesia.  The  use  of  the  latter  compound  is  original  with  the 
author,  and  his  experience  justifies  him  in  recommending  its  use. 
The  latter  compound  is  a  white  powder,  and,  for  use,  must  be 
moistened  and  spread  in  small  amount  over  the  angioma.  This 
acts  more  destructively  than  the  chloride  of  zinc,  and  hence 
caution  is  required  not  to  apply  too  large  a  quantity.  A  few 
hours  after  the  application,  the  structures  underneath  are  black 
and  lifeless;  and  the  dead  eschar  must  be  detached  by  poulticing, 
which  must  be  continued  for  some  days,  to  complete  the  detach- 
ment. The  caustic  potash  may  also  be  used  mixed  with  an  equal 
portion  of  Pulvis  Sanguinarise;    and   the  action  from  this  has 


112  AFFECTIONS    OF    TIIK    SCALP. 

seemed  to  the  writer  to  be  more  severe  than  that  composed  oi 
caustic  potnsli  and  magnesia.  Instead  of  the  external  use  of  the 
potential  caustics,  they  may  be  used  interstitially;  both  tlie 
chloride  of  zinc  and  potassa  fusa  may  thus  be  employed.  The 
chloride  of  zinc,  with  wheaten  flour  made  into  a  paste,  can  be  cut 
into  arrow-shaped  portions,  and  these,  hardened  by  heat,  can  be 
inserted  into  the  openings  made  into  the  growth,  and,  being  left 
there,  they  do  their  work  of  destruction.  The  caustic  potash 
mixed  with  one  of  the  ingredients  mentioned,  may  be  introduced 
into  the  angioma  through  the  canula  of  a  trocar  after  the  stilet 
has  been  withdrawn;  thus  cylinders  of  the  escharotic  may  be 
passed  into  the  angioma,  at  different  points,  and  in  this  way  the 
growth  may  be  destroyed.  A  serious  oljjcction  to  the  method  of 
destruction  by  the  potential  cautery  is  tlie  destruction  of  the  skin, 
and  the  deforming  scar  which  afterwards  remains. 

The  angioma  may  be  removed  by  injecting  into  it  some  agent 
which  will  induce  coagulation  of  blood,  and  as  a  consequence  so 
impair  tlie  nutrition  of  the  growth  as  to  cause  its  atrophy  and 
disappearance.  Agents  employed  to  accomplish  this  work  are 
ergotine,  the  tincture  of  iodine  and  astringent  solutions,  as  that 
of  the  chloride  or  sulphate  of  iron,  alum,  and  the  strong  decoction 
of  oak  bark.  Considerable  trial  has  been  made  of  this  method, 
yet  the  results  obtained  have  not  been  such  as  to  awaken  much 
enthusiasm  on  the  part  of  those  who  have  employed  it.  The  best 
results  have  followed  the  injection  of  tincture  of  iodine  and 
ergotine.  The  coagulating  fluid  is  to  be  introduced  b}"  means  of 
a  hypodermic  syringe,  which  is  caused  to  penetrate  at  different 
jwints,  and  not  more  than  two  or  three  drops  are  to  be  injected  at 
each  point.  The  ergotine  used  and  praised  by  Langenbeck  is 
objectionable  on  account  of  the  pain  it  produces.  The  solution 
of  the  salts  of  iron  used  by  injection  may  arrest  and  prevent 
further  growtli  in  the  angioma,  yet  the  most  serious  objection  to 
these  agents  is  that  the  iron  remains  incorporated  with  the  tissue 
of  the  angioma,  giving  the  same  a  black  color,  so  that  the  work 
ends  by  giving  the  patient  a  black  mark  in  place  of  the  previous 
red  one.  The  tincture  of  iodine  is  free  from  the  objections  which 
can  be  urged  against  the  otlier  agents  mentioned;  and  if  the 
treatment  by  subcutaneous  injection  be  decided  on,  this  agent 
may  be  selected  as  the  best  one.  In  cases  in  which  the  angioma 
contains  large  vessels,  pressure  should  be  kept  up  for  a  time 
around  the  angioma,  so  as  to  retain  the  clotted  material  in  the 
tumor,  and  thus  prevent  its  escape  into  the  general  circulation; 


ANGIOMA.  113 

and  thus  proceeding  one  avoids  the  embolic  closure  of  vessels 
elsewhere.  As  final  injunction  to  those  who  may  adopt  this 
treatment,  let  the  tincture  of  iodine  be  used,  and  the  injection 
only  be  done  with  minimum  amounts  of  the  tincture,  and  repeated 
a  number  of  times,  at  intervals  of  two  days;  and  should  reaction 
indicating  suppuration  appear,  then  the  treatment  should  be 
suspended  until  the  reaction  has  disappeared,  and  resumed  again 
at  longer  intervals. 

The  angioma  may  be  cured  by  vaccination  in  a  subject  who 
has  never  been  vaccinated.  This  is  done  by  introducing  the 
virus  at  different  points  of  the  growth;  and  this  is  not  an  easy 
thing  to  do,  since  the  wounds  made  for  the  insertion  of  the  virus 
bleed  so  freely  that  the  latter  is  washed  away.  Hence  the  plan 
has  been  successfully  tried  of  vesicating  the  surface  with  can- 
tharides,  and  then  placing  over  the  denuded  part  lint  saturated 
with  vaccine  virus.  Or  threads  saturated  with  the  material  may 
be  passed  seton-like  through  the  growth.  It  may  also  be  done  by 
slightly  scarifying,  and  then  placing  the  liquified  virus  on  the 
slight  wounds.  The  work  of  inoculation  might  be  done  with  a 
hypodermic  syringe.  Vaccination  done  in  this  way  takes  a 
j)eculiar  course.  After  the  common  period  of  incubation  the 
vaccine  vesicles  open  and  ulcerate;  the  ulcerating  process  dipping 
inwards,  as  well  as  extending  laterally,  so  that  each  vaccinated 
point  becomes  a  large  open  wound.  In  an  angioma  seated  on  the 
chest  the  author  saw,  from  vaccinating,  an  ulcer  several  inches  in 
diameter,  and  which  was  accompanied  by  so  much  destruction  of 
tissue  that  for  a  time  the  infant's  life  seemed  imperiled.  The 
action  deviated  wholly  from  the  normal  cycle  of  vaccinia;  the 
ulceration  continued  for  a  number  of  weeks;  and,  what  was 
remarkable,  it  appeared  to  follow,  attack  and  break  down  the 
abnormal  vascular  structure,  and  to  leave  the  normal  tissues 
unacted  on.  After  a  tedious  period  of  ulceration,  cicatrization 
ensues  and  continues  until  the  wounded  surface  is  closed  by  a 
white  scar.  In  this  way  an  angioma  of  superficial  character  may 
be  safely  destroyed,  but  where  it  is  of  great  extent  and  penetrates 
deej)ly,  its  removal  had  better  be  tried  by  some  other  means.  An 
objection  to  this  method  is  that,  after  the  surface  is  healed,  it 
retains  the  characteristic  marks  of  the  vaccine  scar.  A  plan 
cognate  to  this  is  that  by  pustulation,  which  may  be  done  by  the 
application  of  croton  oil  or  tartarized  antimony.  The  pustules 
produced  by  tartarized  antimony  have  a  striking  resemblance  to 
those  produced  by  the  vaccine  virus. 


114  AFFECTIONS    OF    THE    SCALP. 

And,  lastly,  the  angioma  may  be  retarded  in  its  growth  by 
compression  continuously  applied  for  a  long  time;  and  in  this 
work  the  surgeon  should  bear  in  mind  that  the  angioma  often 
continues  to  grow  until  the  subject's  body  has  attained  its  final 
term  of  development.  It  is  stated  tliat  infantile  angioma  has 
been  cured  by  compression  maintained  by  the  mother's  hand; 
it  is  j)robable  that  the  successful  continuance  of  such  a  task  could 
only  be  maintained  by  maternal  affection.  Compression,  indi- 
rectly used,  has  been  obtained  by  astringents  used  locally;  cures 
thus  obtained  have  oeen  announced.  As  a  substitute  for  the 
mild  action  of  an  astringent,  the  contractile  action  of  collodion 
might  be  used.  For  this,  the  best  quality  of  collodion  should  be 
employed;  and  of  this  a  thick  coating  should  be  applied  on  and 
around  the  afifected  structure.  The  long  continuance  of  this 
might  induce  atrophic  regression  of  the  vascular  structure. 
Fingers,  even  the  mothers,  may  tire;  the  action  of  astringents 
may  prove  impotent;  and  collodion  through  its  ethereal  ingredient 
must  irritate  and  cause  pain;  hence,  if  compression  be  selected 
for  the  cure  of  the  angioma,  some  mechanical  way  of  accomplishing 
it  should  be  used.  Such  com})ression  may  be  made  by  means  of 
a  pad  similar  to  that  of  a  truss;  to  the  truss  straps  may  be 
attached  made  of  leather  or  of  India  rubber,  and  such  straps  are 
to  be  carried  around  the  head  and  fastened  by  buckles,  so  as  to 
remain  in  place  and  exert  a  continued  pressure.  As  already 
5aid,  this  compression  must  be  continued  an  indefinitely  long- 
period  to  accomplish  its  purpose. 

Vascular  Growths.— Besides  the  growths  which  arise  from 
abnormal  development  of  the  capillaries,  which  have  been 
described  as  very  frequently  occurring  in  the  scalp,  there  are  seen 
there  tumors  in  which  the  leading  constituents  are  vessels  of 
larger  caliber;  and  such  tumor  may  consist  of  veins  alone,  or 
veins  and  arteries  may  unite  in  the  formation,  or  the  growtli  ma}'- 
be  wholly  arterial. 

From  the  position  of  the  veins  of  the  scalp,  in  which  the  force 
of  gravitation  is  slight  or  absent,  venous  dilatation,  occurring  so 
often  in  the  lower  part  of  the  body,  is  rarely  seen  in  the  head. 
And  where  such  widening,  named  phlebectasis,  is  found  in  the 
scalp,  it  is  a  result  of  congenital  enlargement,  in  which  the  veins 
are  primordially  dilated;  and,  in  some  cases,  this  irregular 
development  continues  after  birth,  until  an  extensive  portion  of 
the  scalp  becomes  affected.  The  overlying  skin  becomes  atten- 
uated and  livid  in  hue,  and  the  affected  structure  when  opened 


VASCULAR    GROWTHS.  115 

to  view  seems  intrenched  with  irregular  channels,  on  the  walls  of 
which  the  pigmentary  matter  of  the  blood  is  usually  found 
deposited.  Ordinarily  such  venous  growth  is  painless,  and,  having 
reached  a  certain  volume,  it  ceases  to  grow.  The  hair,  in  part  or 
in  whole,  falls  from  the  affected  structure. 

Not  unfrequently,  along  with  the  venous  dilatation,  the 
arteries  undergo  a  similar  change,  the  condition  then  being 
named  arterio-venous  aneurism.  This  form  resembles  simple 
phlebectasis,  yet  in  such  growth  there  may  be  felt  the  vibratile 
thrill  of  the  widened  arteries;  and  rising  and  falling  movement 
of  the  superjacent  surface  is  also  visible;  and  if  touched  it  will  be 
found  warmer  than  parts  adjoining.  In  a  case  of  this  vascular 
growth  seen  by  the  author,  the  greater  portion  of  the  scalp  was 
affected.  The  man  who  was  the  subject  of  this  growth  was  over 
fifty  years  of  age;  it  had  existed  many  years.  The  vascular 
development  seemed  to  be  greater  in  the  deeper  portion  of  the 
scalp,  and  as  accurately  as  could  be  estimated  by  palpation,  it 
was  an  inch  in  depth.  This  increased  thickness  was  not  wholly 
due  to  the  vessels,  but  depended  on  growth  of  the  tissues  which 
lay  around  the  vessels.  This  development  had  arisen  from  the 
irritation  caused  by  the  pressure  of  the  encroaching  vessels.  This 
growth,  commencing  near  the  summit  of  the  head,  reached  down- 
wards on  one  side  of  the  forehead;  the  structures  of  one  pinna 
were  affected.  This  growth  was  not  painful,  yet  it  was  the  sight 
of  a  vibratile  movement  and  a  buzzing  sound  which  was  very 
annoying  to  the  patient;  and,  for  relief  from  this  constant  sound, 
the  man  sought  surgical  aid.  The  growth  was  too  extensive  to 
admit  of  removal;  in  fact,  any  of  the  known  methods  for  the  care 
of  such  a  morbid  development  are  too  perilous  to  life,  and  should 
not  be  advised  unless  the  growth  has  become  such  a  burden  to 
the  patient  that  he  is  willing  to  risk  his  life  in  the  effort  to  find 
relief;  and  in  that  event  a  recourse  might  be  had  to  arterial  liga- 
tion. The  supply  of  blood  might  be  cut  off  by  tying  the  external 
carotid  arteries.  The  ligation  of  these  vessels,  though  mechani- 
cally difficult,  is  not  a  severe  assault  on  the  patient;  and  it  should 
be  tried  in  preference  to  excision,  or  parenchymiatous  injection  of 
some  agent  to  cause  coagulation.  The  ligation  of  one  carotid 
would  be  insufficient,  since  through  the  remaining  untied  artery 
the  blood  would  soon  reach  and  fill  the  growth.  Instead  of  liga- 
tion, an  attempt  to  relieve  might  be  made  by  direct  compression 
of  the  affected  structure;  in  this  way  the  growth  might  be  pre- 
vented from  further  development;  and,  besides  this  action,  if  the 


110  AFFECTIONS    OF    THE    SCALP. 

growth  had  reached  such  dimensions  as  to  seriously  tinnoy  the 
possessor  by  its  buzzing  fremitus,  then  the  latter  might  be  lessened 
b}'  a  properly  adjusted  compress.  Pressure  should  not  be  too  great, 
lest  it  might  cause  abrasion  of  surface,  and  thus  cause  haemor- 
rhage. 

Aneurism  occurs  in  the  vessels  of  the  scalp;  but  before  consid- 
ering it,  a  brief  consideration  of  the  subject  of  aneurism  should 
precede.  The  medical  etymologist  finds  difficulty  in  discovering 
the  origin  of  the  term;  the  author  thinks  he  finds  traces  of  it  in 
the  Greek  preposition  ana,  meaning  up  or  upwards,  and  eurys,  an 
adjective  meaning  wide;  and  the  name  thus  constructed  signifies 
an  upward  widening.  An  aneurism  is  a  hollow  tumor  of  irreg- 
ularly rounded  outline,  which  arises  from  an  artery  into  which 
the  cavity  of  the  tumor  opens,  and  which  is  filled  with  blood  in 
irregular  motion.  The  walls  of  the  tumor  are  continuous  with 
those  of  the  artery  w^hence  it  springs;  and  when  these  walls  are 
complete,  one  finds  in  them  the  three  tunics  which  constitute  the 
walls  of  the  artery;  or  some  of  the  tunics  may  be  wanting.  Hence 
arises  the  classification  of  true  and  false  aneurism;  in  the  wall  of 
the  true  class  no  tunic  is  wanting,  but  in  the  false,  called  also 
the  mixed  form,  the  w^all  may  be  composed  only  of  the  external 
arterial  coat;  or  the  external  and  middle  tunic  may  have  been 
ruptured,  and  then,  in  this  rare  form,  only  the  innermost  tunic 
will  be  found,  forming  the  wall  of  the  aneurism.  The  wall  of  the 
aneurism  has  been  the  matter  of  discussion;  some  claim  that  with 
careful  dissection  all  three  tunics  may  always  be  discovered,  and 
that  their  continuation  with  the  normal  tunics  of  the  artery  can 
be  traced  out. 

In  another  form  akin  to  the  false  species,  the  wall  has  no 
direct  anatomical  connection  with  the  Avail  of  the  vessel;  and 
since  it  arises  from  an  injury  in  which  the  vessel  is  opened,  such 
aneurism  is  named  traumatic.  An  essential  condition  here  is 
that  the  artery  be  surrounded  by  soft  parts,  into  which  the  blood, 
escaping  from  the  torn  vessel,  forces  itself  and  forms  a  hollow 
cavity.  In  time,  around  such  cavity  there  is  formed  an  irregu- 
larly organized  wall,  which  prevents  the  further  diffusion  of  the 
blood  into  the  neighboring  structures.  In  case  the  rupture  is  in 
a  vessel  which  lies  in  a  cavity,  where  it  is  not  walled  in  by  other 
structures,  then  a  fatal  haemorrhage  can  ensue;  such  has  been 
seen  in  the  thorax  and  abdomen. 

True  and  false  aneurism  may  be  conjoined;  namely,  one  aris- 
ing from  an  artery  and  contained  in  the  distended  tunics  of  the 


VASCULAR    GROWTHS.  117 

vessel  may  burst,  and  form  a  hollow  in  the  parts  adjacent,  and 
the  latter  form  a  containing  wall. 

The  connection  of,  and  communication  of  the  aneurism  with, 
the  supporting  artery,  may  be  termed  its  pedicle  or  base,  and  the 
form  and  extent  of  this  base  have  an  important  bearing  on  the 
course  of  the  aneurism.  When  an  aneurism  has  ceased  to  enlarge, 
there  is  a  tendency  to  spontaneous  occlusion  of  its  cavity.  This 
occlusion  occurs  through  the  agency  of  the  cellular,  fibrinous,  and 
albuminous  constituents  of  the  blood,  which  in  solid  form  are 
deposited  on  the  wall  of  the  cavity,  so  that  this  wall  slowly  thick- 
ens at  the  expense  of  the  inner  cavity.  This  deposition  is  from 
the  blood,  which  is  stagnant  or  in  torpid  motion,  and  the  stagna- 
tion or  tardy  movement  is  favored  by  the  narrowness  of  the  open- 
ing in  the  aneurism.  The  materials  thus  precipitated  become 
organized  and  are  stratified,  so  that  the  superadded  structure  is 
separable  into  layers.  This  is  tinged  .with  the  pigment  of  the 
blood.  The  formation  of  this  material  depends  on  a  due  amount 
of  blood  which  enters  the  aneurismal  cavity,  and,  tardily  moving 
there,  again  escapes  into  the  onwardly  moving  current  of  blood. 
Spontaneous  rupture  seldom  or  never  occurs,  where  the  tumor  is 
inclosed  by  other  structures;  and  bursting  there  occurring  would 
be  from  some  violence.  Nevertheless  the  pulsatile  movement,  or 
action  of  an  aneurism,  on  neighboring  parts,  tends  to  attenuate 
the  latter.  Bone  thus  becomes  eroded  or  softened,  and  disappears 
similar  to  a  rock  over  which  the  watery  tide  constantly  ebbs  and 
flows. 

As  stated,  there  is  a  tendency  in  every  aneurism  to  become 
occluded  through  concentric  growth  or  thickening  of  its  walls; 
this  work  is  tardy  and  uncertain  of  its  aim,  so  that  in  case  the 
tumor  lies  external,  or  is  accessible,  the  surgeon's  aid  is  invoked. 

To  favor  and  accelerate  the  deposition  of  the  occluding  material 
two  methods  are  prominently  in  use, — ligation  and  compression. 
Ligation,  introduced  by  John  Hunter  for  the  cure  of  popliteal 
aneurism,  has  been  resorted  to  for  the  cure  of  aneurism  elsewhere. 
There  are  different  plans  of  ligating.  It  may  be  done  between 
the  heart  and  the  tumor,  or  on  the  distal  side  of  the  tumor. 
Hunter's  method  was  to  tie  at  some  distance  from  the  aneurism 
on  the  cardiac  side.  Anel  and  others  advised  to  ligate  on  the 
cardiac  side  close  to  the  tumor.  Aneurism  may  be  cured  by  each 
of  these  plans,  though  that  of  Hunter  is  more  commonly  prac- 
ticed. An  exceptional  method  is  the  ligation  of  the  artery 
beyond  the  tumor,  known  as  Brasdor's  operation;  and  a  modifi- 


118  AFFECTIONS    OF    THE    SCALP. 

cation  of  this  method  is  the  tying  of  the  two  branches  into  ^Yhich 
the  vessel  bifurcates  beyond  the  aneurism;  and  this  method  is 
named  from  its  introducers,  the  operation  of  Brasdor  and  Ward- 
rop.  Ligation  beyond  tlie  aneurism  has  been  chiefly  done  on  the 
carotid  and  subclavian  arteries. 

Aneurism  has  been  cured  by  compression  made  on  the  afferent 
vessel,  on  the  cardiac  side  of  the  tumor;  and  this  compression 
may  be  done  close  to  the  tumor  or  at  a  distance  from  it.  Again, 
the  work  lias  been  successfully  done  by  pressure  made  directly  on 
the  aneurismal  tumor.  Such  compression  may  be  done  with  the 
human  hand,  or  it  may  be  done  by  means  of  an  instrument. 

And  finally,  a  method  of  cure  known  as  tliat  of  Anthyllus,  is 
that  in  which  the  aneurismal  tumor  is  opened,  cleaned  of  its 
clots,  and  the  entering  and  emerging  portions  of  the  artery  are 
ligated.  This  niethod  is  only  applicable  to  aneurism  seated  on 
small  vessels,  and  usually  such  as  have  arisen  from  tiie  rupture 
of  the  vessel,  that  is,  in  traumatic  aneurism.  It  would  be  wholly 
inapplicable  for  the  cure  of  an  aneurism  arising  from  a  large 
artery.  A  plan  cognate  to  this  has  recently  been  practiced, 
viz.,  to  tie  the  artery  on  each  side  of  the  aneurysmal  tumor, 
and  then  dissect  out  the  latter. 

The  arteries  of  the  scalp  are  of  diminutive  caliber,  and  are 
rarely  the  site  of  aneurism;  and  when  this  occurs  it  is  commonly 
of  traumatic  origin;  sucli  aneurism  is  met  with  in  the  frontal  and 
temporal  regions  of  the  head.  The  usual  cause  is  a  penetrating 
wound  or  violence  on  the  part  through  a  fall,  blow  or  moving 
missile.  The  dense  structures  in  which  the  vessel  lies  imbedded 
prevents  the  aneurism  from  attaining  a  large  volume. 

Aneurism  seated  in  the  scalp  tends  to  spontaneous  occlusion; 
yet  this  mode  of  ending  is  slow  of  accomplishment.  Hence  it  is 
better  to  hasten  tiiis  desired  event  by  the  selection  of  some  of  the 
means  previously  described.  Direct  compression  should  first  be 
tried,  since  it  causes  no  scar  and  is  bloodless — conditions  always 
agreeable  to  the  patient.  For  this  purpose  let  a  compressing  pad 
be  constructed  of  yielding  material,  such  as  soft  leather  or  India 
rubber,  and  let  this  be  placed  on  the  tumor  and  be  fastened  there 
by  retaining  straps.  By  such  an  appliance  continued  compres- 
sion may  be  made  on  the  tumor;  enougli  of  force  must  be  used 
to  flatten  the  tumor  and  arrest  the  pulsatile  movement  in  the 
latter.  The  author  has  seen  a  traumatic  aneurism  of  the  frontal 
artery  thus  compres-sed,  and  a  cure  effected  after  a  few  weeks' 
continuance  of  the  treatment.     Should  this  fail,  the  tumor  might 


INFANTILE    SANGUINEOUS    TUMOR.  119 

be  opened  and  the  vessel  tied  on  each  side;  this  method  would 
surely  cure,  but  also  scar  the  patient. 

Infantile  Sanguineous  Tumor. — The  newborn  child  usually 
presents  a  swelling  of  greater  or  less  extent  on  the  parietal  region 
of  the  head.  This  tumor  or  tumefaction  is  caused  by  the  violence 
to  which  the  head  is  subjected  during  its  passage  from  the  uterus 
through  the  pelvic  outlet.  It  is  commonly  located  on  the  upper 
and  posterior  part  of  the  head,  which  corresponds  to  the  posterior 
portion  of  the  right  parietal  bone.  There  are  two  forms;  in  one, 
the  blood  is  diffused  through  the  soft  tissues  by  simple  extrava- 
sation ;  the  capillaries  are  dilated  or  burst;  the  greater  part  of  the 
swelling  is  due  to  effused  blood,  since  mere  swelling  of  the  capil- 
laries cannot  account  for  the  greatly  increased  volume  of  the 
part.  In  another  form  there  is  a  collection  of  blood  which  rests 
on  the  cranium,  and  is  separated  from  the  parts  around  by  an 
imperfectly  formed  wall.  The  infiltrated  form,  first  mentioned, 
is  due  to  the  jDrotracted  delivery ;  the  head  having  partly  pro- 
truded through  the  os  uteri  remains  there  for  some  time,  while 
the  surrounding  uterine  neck  grasps  the  retained  head  like  a 
strangulating  band.  The  form  of  this  tumor  is  that  of  a  non- 
pedunculated  growth,  which  is  soft  and  slightly  elastic.  During 
the  progress  of  labor  this  protrusion  can  be  felt,  and  also  observed 
to  elongate  during  the  time  of  the  uterine  expulsive  acts,  and  its 
volume  is  increased  proportionately  to  the  length  of  the  labor, 
the  causal  mechanism  being  in  the  firm  and  resistant  collum 
uteri,  which,  during  the  pains  of  labor,  catches  and  holds  the 
dependent  portion  of  the  scalp,  and  ties  off,  as  it  were,  a  portion 
of  blood  from  the  general  circulation. 

This  vascular  tumefaction  seldom  requires  attention;  if  any- 
thing be  done,  it  may  be  limited  to  protecting  the  part  with 
cotton  wadding,  and  the  application  of  camphorated  liniment. 
Sometimes,  however,  the  quantity  of  effused  blood  is  too  great 
to  be  absorbed,  and  the  result  is  suppuration,  in  which  there  is 
formed  an  ichorous  fluid,  which  is  required  to  be  liberated  by 
an  incision  of  the  overlying  skin.  There  should  not  be  haste  to 
do  this,  since  unaided  nature,  usually,  can  effect  a  cure. 

In  the  second  form,  in  which  there  is  a  collection  of  dark, 
grumous,  uncoagulated  blood,  absorption  of  this  fluid  sometimes 
occurs;  yet  in  many  cases  the  fluid  remains,  and  the  containing 
parts  show  by  their  heat  that  there  is  inflammation  tending  to 
breaking  down  and  opening  of  the  cavity.  In  such  condition 
the  cavity  should  be  opened,  and  after  the  blood  has  been  evacu- 


120  AFFECTIONS    oF    THE    SCALP. 

ated,  the  containing  space  should  be  washed  out  with  an  alcoholic 
or  sublimated  solution.  In  lieu  of  this  an  emulsion  of  iodoform 
might  be  injected.  In  the  em])tying  of  such  cavit}',  care  must 
be  taken  not  to  press  violently  on  it,  as  there  is  danger  of  re- 
opening the  afferent  vessels;  if  this  should  be  done,  the  cavity 
would  quickly  refill.  This  has  occurred  in  the  author's  practice. 
After  the  evacuation  and  wasliing  out  of  the  cavity,  slight  pres- 
sure with  a  compress  of  cotton  wadding  should  be  fixed  over  the 
cavity;  thus  closure  is  promoted.  Nevertheless,  it  is  rare  that 
one  evacuation  suffices;  the  cavity  partly  refilling  will  probably 
demand  reopening  once  or  twice  again,  before  a  cure  is  efiected. 
And,  despite  these  precautionary  measures,  su})puration  may 
occur  and  entail  a  tedious  recovery. 

Pigment  Marks. — The  chapter  on  benign  tumors  of  the  scalp 
would  he  incomplete  without  considering  pigmentary  marks  of 
congenital  origin,  which  are  of  occasional  occurrence.  Such 
marks  are  dark  or  black  in  color,  and  are  commonly  accom- 
panied by  increased  thickness  of  the  affected  part;  and,  if  covered 
with  hair,  the  latter  is  luxuriant  in  growth  and  sometimes  of 
intense  blackness.  Such  growth  may  occupy  a  large  surface, 
even  to  the  extent  of  three  or  four  inches.  The  author  has  met 
with  two  examples  which  were  seated  on  the  anterior  portion  of 
the  cranial  vault,  and  extended  from  the  coronal  suture  forwards 
to  the  eyebrow,  on  one  side.  This  coloring  of  Ethiopian  black- 
ness w^as  congenital  in  each  case.  The  limit  between  the  normal 
and  abnormal  parts  was  clearly  defined;  and  in  one  case  the 
hair  was  several  times  the  length  of  that  on  the  unaffected  por- 
tion of  the  head.  Such  pigmentation  does  not  appear  inclined 
to  spread  beyond  the  limits  it  has  at  birth.  The  affected  structure 
is  not  erectile;  nor  on  section  does  it  seem  very  vascular.  It  is 
probable  that  such  growth  originates  from  a  capillary  angioma 
wdiicli  has  undergone  retrograde  transformtion. 

This  pigmented  growth  is  a  serious  inheritance  to  a  newborn 
child,  since  it  fatally  disfigures  the  head,  especially  when  it 
reaches  down  on  the  forehead.  The  author,  though  familiar 
with  infantile  deformity,  carries  in  memory  pictures  of  the  two 
cases  mentioned,  traced  with  unusual  vividness;  and  especially 
does  he  recall  the  parental  ap})eal  for  surgical  aid,  even  though 
such  aid  in  removing  the  mark  should  remove  tiie  infant.  In 
the  cases  mentioned  life  was  saved,  though  extensive  excision 
was  done.  To  do  this  properly,  the  cutting  must  reach  quite 
through  the  scalp;  and  the  operator  must  be  sure  that  his  inci- 


MALIGNANT    GROWTHS.  121 

sion  reaches  beyond  the  affected  structure;  for  a  small  marginal 
portion  left  will  remain  as  a  black  seam  on  the  border  of  the 
cicatrix.  In  this  work  divided  vessels  must  be  seized  and  ligated. 
Partial  closure  of  the  wound  should  be  attempted,  even  though 
the  breach  made  be  a  large  one;  by  lateral  displacement  the 
wound  may  be  materially  lessened  in  extent,  an-d  opposite  bor- 
ders may  thus  be  made  to  coalesce.  Wire  and  catgut  sutures 
must  be  used  for  the  closure.  The  wire  sutures  niust  be  so  placed 
as  to  fix  the  parts  and  relieve  them  from  tension,  while  those  of 
catgut  must  effect  accurate  union.  Heemorrhage  being  controlled, 
and  the  part  being  sprinkled  with  iodoform,  it  is  to  be  covered 
deeply  with  lint  which  has  been  saturated  with  the  compound 
tincture  of  benzoin,  and  held  by  adhesive  strips,  which  surround 
the  head.  Such  a  dressing  may  remain  in  place  for  a  week,  or 
longer,  should  there  be  no  discharge;  and  afterwards  changed  as 
occasion  may  demand.  In  this  work  of  excision,  should  hair, 
cither  of  the  scalp  or  the  brow,  be  removed,  the  cicatrix  will 
afterwards  remain  bald.  In  case  of  an  eyebrow,  this  should  be 
announced  to  the  parents  beforehand,  since  no  art  will  supple- 
ment the  loss. 

Malignant  Growths. — The  author  will  next  consider  malignant 
growths  which  occur  in  the  scalp. 

AVhence  the  malignant  growth  arises,  to  what  extent  spon- 
taneous evolution,  traumatism  and  indeterminate  contingency 
figure  as  elements  of  causation,  how  far  the  tendencies  of 
ancestry,  distant  or  proximate,  as  transmitted  heredity,  may 
influence  such  growth,  whether  cell  or  microphyte  may  be  the 
primary  causal  agent,  are  c[uestions  which  have  been  asked, 
and  will  continue  to  be  asked,  until  this  department  of  Pathol- 
ogy has  reached  a  stage  of  unquestionable  fact,  far,  very  far, 
from  where  the  writer  now  finds  it.  Though  much  is  known 
here,  probably  much  more  remains  unknown.  The  best  work 
in  this  field  will  be  done  by  those  who  combine  in  themselves 
the  theoretical  pathologist  and  the  practical  clinician;  those 
in  whom  the  exuberances  of  theory  will  be  lopped  off  or 
corrected  by  observation  and  study  of  the  thing  as  it  exists 
in  nature.  And,  though  such  students  of  nature  labor  ear- 
nestly and  diligently,  yet  the  line  of  progress  only  slowly 
approaches,  and  rarely  reaches  the  line  of  truth;  and  it  finds  an 
analogue  in  mathematical  lines,  as  the  inclining  sides  of  the 
oblique  parallelogram,  which,  though  indefinitely  prolonged,  ever 
draw  nearer,  vet  never  touch  each  other.     Illustrations  of  how 


Vl'l  AFFECTIONS    OF    THE    SCALP. 

much  labor,  reaching  through  many  generations,  is  needed  to 
phick  up  error  which  has  taken  deep  root  in  tiie  human  mind, 
may  be  seen  in  the  example  of  how  long  the  notion  lived  that 
inorganic  nature  was  constituted  of  four  elements, — earth,  air,  fire, 
and  water, — and  an  analogue  is  also  seen  in  the  long  shadow 
of  error  which  "was  projected  over  the  field  of  medicine  by  the 
doctrine  of  the  four  elements  which  were  thought  to  constitute 
organic  beings,  viz.,  blood,  phlegm,  bile,  and  atrabile;  and  from 
these  elements  the  old  pathologist  derived  phlegmon,  dropsy 
(oedema),  erysipelas,  scirrhus,  and  the  family  of  tumors.  Atra- 
bile was  the  element  whence  sprang  all  preternatural  growths. 
Medical  science  bowed  its  head  to  tliis  idol,  moulded  into  such 
enduring  form  by  the  hands  of  Hippocrates  and  Galen.  These 
old  notions,  formulated  so  neatly  and  become  sacred  through 
traditional  preservation,  were  parted  with  reluctantly.  Yet  the 
eighteenth  century  gave  medicine  many  heretics,  who  renounced 
many  of  the  old  doctrines,  who  read  facts  as  they  are  recorded  in 
the  tissues,  sound  and  unsound,  rather  than  their  misinterpreta- 
tions as  treasured  up  in  the  parchment-bound  tomes  of  antiquity; 
and  none  plucked  up  more  weeds  of  error,  and  planted  more 
truths  in  their  stead,  than  John  Hunter.  And  into  this  field,  hith- 
erto so  little  trodden  by  the  foot  of  patient  research,  the  nine- 
teenth century  has  sent  a  host  of  diligent  workers,  among  the 
most  famous  of  which  may  be  mentioned  Paget,  Virchow,  Wal- 
deyer,  Cornil,  and  Ranvier.  From  the  numerous  facts  which 
have  been  brought  to  light  by  these  students  of  abnormal  growth, 
a  few  M'ill  be  presented  to  the  reader  concerning  sarcoma  and 
epithelioma,  forms  of  malignant  growth  met  with  in  the  scalp. 
Sarcoma,  literally  flesh  tumor,  has  had  a  changeable  history, 
as  soon  becomes  apparent  when  one  attempts  to  study  the  liter- 
ature upon  this  subject,  and  tries  to  form  a  clear  notion  of  what 
is  meant  by  this  term.  After  mucli  errant  search  for  exact  knowl- 
edge, in  which  the  student  is  often  lost  or  puzzled  by  vague 
descriptions  of  tissues  seemingly  very  different,  the  fact  is  finally 
grasped  that  the  various  elements  of  the  animal  body  are  held  in 
union  by  a  web,  which,  from  its  office,  is  named  connective  tissue; 
through  this  the  peculiar  elements,  Avliich  distinguisli  the  derm, 
muscles,  bones,  glands  and  otlier  organs  of  the  body,  are  held 
together,  and  the  special  structures  individualized;  and,  finally, 
it  has  been  observed  that  this  connecting  structure  is  the  starting 
point  of  a  large  group  of  malignant  growths.  To  the  growth 
which   originates   from  connective   tissue   the  name  sarcoma  is 


MALIGNANT    GROWTHS.  123 

applied;  and  as  connective  tissue  abound  everywhere,  hence 
arises  the  regional  universality  of  sarcoma.  And  if  the  writer 
has  not  erred  in  his  observation,  besides  the  connective  tissue, 
the  parenchymatous  elements  which  the  latter  unites,  may 
exceptionally  be  the  starting-point  of  sarcomatous  development. 
Nay,  more,  the  epithelial  elements  may  stray  from  normal  line 
and  contribute  to  sarcomatous  formation.  And  such  deviation 
finds  a  parallel  in  the  license  sometimes  taken  by  epithelioma, 
since,  in  the  latter,  cells  of  connective-tissue  origin  sometimes  occur. 
In  the  healing  of  wounds,  both  concealed  and  open,  repair  is 
accomplished  through  the  medium  of  cells  which  originate  partly 
from  the  adjacent  connective  tissue,  and  partly  from  colorless 
blood-cells,  which  have  escaped  from  the  contiguous  vessels. 
This  reparative  material,  having  reached  the  limits  which  cor- 
respond to  normal  form,  ceases  to  grow,  and,  as  it  does  so,  the 
component  elements  are  transformed  into  fibrous  tissue.  When 
the  sarcoma  is  studied  in  reference  to  its  cellular  constituents,  it 
is  found  to  be  singularly  similar  in  composition  to  the  structure 
that  repairs  the  wound.  Both  structures  present  us  with  the 
same  nucleated  round  cells,  regularly  arranged  around  vessels 
which  traverse  the  developing  structure.  The  similarity,  so 
marked  in  the  early  stages  of  the  two  structures,  vanishes  at  a 
later  period;  the  one  becomes  on  the  surface  of  the  body  a  scar, 
hard,  fibrous  and  non-vascular.  The  sarcoma  may  undergo  a 
similar  change,  yet,  as  a  rule,  it  is  stamped  by  the  jDermanency 
of  its  round  cell-form;  hence  the  name  of  the  round-celled 
sarcoma.  But  these  cells,  similar  to  those  of  granulated  tissue, 
do  sometimes  undergo  a  species  of  development  or  transforma- 
tion; the  cells  become  organized  into  a  tissue  of  fusiform  or  doubly 
conoidal  fibers;  and  this  species  is  named  the  fusiform  or  spindle- 
celled  sarcoma.  The  round  cells  and  spindle-shaped  cells  are, 
usually,  found  combined  with  some  growth.  The  student  of  the 
microscope  will  soon  learn  here,  as  he  has  already  learned  in  his 
study  of  other  structures,  that  there  are  many  deviations  from 
the  leading  or  typical  forms;  that  though  there  are  many 
approaches  towards  roundness  of  cell  form,  yet  there  are  few  cells 
which  are  perfectly  round;  and,  likewise,  that  the  schematic 
spindle-cell,  so  familiar  to  the  eye  in  plates,  is  a  rarity  in  nature, 
which,  delighting,  here  as  elsewhere,  in  freedom,  spurns  uniform- 
ity and  revels  in  variety.  Exact  type,  definite  rule,  and  measured 
division  of  parts,  are  valuable  aids  in  the  acquisition  of  knowl- 
edge, and  they  further  mental  discipline;  yet  these  artifices  are 


124  AFFECTIONS   OF    THE    SCALP 

unknown  to  nature,  a  fact  wliich  the  experienced  student  soon 
learns  to  his  regret,  and  for  which  he  must  make  due  allowance 
everywhere,  and  nowhere  more  than  in  the  tield  of  Pathology. 
The  minute  components  of  pathological  structures  must  he  viewed 
again  and  again  with  untiring  patience  before  order  appears  and 
confusion  vanishes;  thus  working,  the  typical  at  length  asserts  its 
presence  and  predominance,  and  the  non-typical  and  amorphous 
are  lost  sight  of.  Having  reached  such  a  stage  of  proficiency, 
one  readily  descries  and  distinguishes  the  round  cells  of  the 
.sarcoma,  many  of  which  through  pressure  or  manipulation  have 
become  irregularly  polygonal  or  elliptically  elongated.  Also, 
along  with  these  rounded  forms  may  be  often  seen  figures  of 
shuttle-form,  or  similar  in  shape  to  the  oat-grain;  these  are  the 
spindle  or  fusiform  cells.  One  or  the  other  of  these  cell-forms 
jiredominating  assigns  the  sarcoma  to  the  round-celled  or  fusiform 
species.  In  the  latter  there  has  been  an  effort  at  organization  in 
the  transformation  of  the  round  embryonic  cells  into  the  long 
forms  simulating  fibers;  such  a  tumor  is  indurated  and  is  fascicu- 
lated in  texture. 

A  third  form  of  this  tumor,  which  has  been  particularly 
described  by  Sir  James  Paget,  is  that  known  as  the  giant-celled 
sarcoma,  this  name  being  given  on  account  of  the  enormous  size 
of  the  constituent  cells.  The  giant-cells,  when  carefully  exam- 
ined, are  seen  to  be  compound  forms,  that  is,  cells  in  which  a 
number  of  nucleated  round  cells  are  packed  in,  and  held  together 
by,  a  common  containing  envelope.  A  similar  giant-cell  has 
been  found  in  the  syphilitic  gummy  tumor  and  in  exuberant 
granulation.  As  a  cell  of  this -character  is  a  normal  constituent 
of  fetal  marrow,  it  has  been  designated  the  myeloid  cell. 

In  the  three  forms  of  sarcoma  described,  the  component  cells 
lie  in  contact,  or  are  exceptionally  separated  by  an  amorphous 
intercellular  substance. 

In  the  development  of  tlie  sarcoma,  along  with  the  production 
of  cells,  there  is  also  a  vascular  growth;  vessels  of  minute  capil- 
lary form  are  developed  in  the  tumor.  And  these  vessels  are 
more  numerous  in  proportion  as  the  sarcoma  is  more  closely  allied 
to  the  embryonic  type,  that  is,  to  the  round-cell  species.  There 
is  a  similarity  between  the  vessels  of  granulative  and  sarcoma- 
tous tissue;  yet  the  vessels  in  the  granulation  are  more  highly 
organized  than  in  the  sarcoma;  in  the  latter  they  are  of  a  very 
rudimentary  form,  and  are  easily  ruptured.  Hence,  from  slight 
violence  the  vessels  of  the  sarcoma  may  be  torn  and  blood  eftused 


MALIGNANT    GROWTHS.  125 

into  the  tissue.  The  constituent  cells  lie  in  immediate  contact 
with  the  vessels,  in  this  respect  differing  from  the  vascular 
arrangement  of  carcinoma,  in  which  the  vessels  are  separated 
from  the  characteristic  carcinomatous  cells  by  a  layer  of  tissue. 

The  sarcoma  viewed  niacroscopically  presents  itself  in  differ- 
ent species  or  varieties;  thus  we  have  forms  of  it  which  are 
named  encephaloid,  fasciculated,  ossified,  and  myeloid. 

Encephaloid  sarcoma  is  constituted  of  round  cells  and  vessels; 
in  structure  it  is  very  analogous  to  that  of  the  early  embryo,  viz., 
a  compound  of  very  rudimentary  cells  grouj)ed  around  minute 
vessels.  The  cells  and  vessels  grow  rapidly,  and  sooner  or  later 
the  cell  growth  outstrips  the  vascular  growth;  and  then  the  cells 
which  are  most  distant  from  the  vessels  perish  from  defective  nutri- 
tive supply;  and  if  this  be  within  the  growth,  a  collection  of  semi- 
liquid  material  appears,  which  in  composition  may  be  compared 
to  ill-formed  pus;  and  if  such  disintegration  occurs  near  the  sur- 
face of  the  tumor,  then  the  integument  of  the  latter  may  open 
and  an  unhealing  ulcer  result.  With  such  characteristics,  the 
encephaloid  sarcoma  is  entitled  to  a  place  among  malignant 
growths  of  a  highly  destructive  tendency. 

The  fasciculated  form  of  sarcoma  is  one  in  which  there  are 
efforts  at  organization;  the  most  of  the  round  cells  are  converted 
into  imperfect  fibers;  and  these  are  disposed  in  an  irregularly 
lamellated  order,  so  that  when  an  opening  is  made  in  the  surface, 
and  the  tumor  torn  open,  the  torn  surface  presents  a  stratified 
appearance.  This  species  is  less  vascular  tlian  the  encephaloid 
sarcoma;  it  grows  less  rapidly,  and  as  it  does  not  reach  such 
dimensions  as  the  encephaloid  species,  its  presence  may  be  toler- 
ated a  much  longer  time.  The  fasciculated  variety  is  often  found 
in  connection  with  muscular  tissue;  and  the  stratified  form  of  the 
muscle  may  be  regarded  as  the  prototypal  model,  according  to 
which  is  developed  its  abnormal  correlate,  the  fasciculated 
sarcoma. 

The  ossifying  or  osteal  form  is  seen  in  the  sarcoma  which 
originates  from  periosteum  or  bone.  And,  exceptionally,  the 
bony  tissue  is  developed  within  the  sarcomatous  tumor  which  is 
not  contiguous  to  bone,  especially  in  sarcoma  that  is  of  the  typi- 
cally fasciculated  species.  When  it  occurs  in  the  growth  not 
adjacent  to  bone,  the  origin  of  the  osteal  tissue  cannot  be  so 
readily  accounted  for  as  when  found  in  a  growth  having  con- 
nection with  some  bone  of  the  skeleton;  in  the  latter  case  there 
can  be  traced  propagation  by  continuity.     The  bony  tissue  in  the 


120  AFFECTIONS    OF    THE    SCALP. 

isolated  sarcoma  is  produced  similarly  to  that  of  the  upper  half 
of  the  foetal  cranium,  in  which  the  bones  grow  directly  from 
fibrous  structure,  without  the  intermediate  cartilaginous  stage 
which  occurs  in  the  growth  of  the  bones  at  the  base  of  the  skull; 
and  this  latter,  as  the  hlstologist  knows,  is  the  normal  mode  of 
development  of  the  other  bones  of  the  body;  consequently  the 
bone  in  sarcoma  is  not  without  a  physiological  analogue.  The 
partially  ossified  sarcoma  has  a  long  course;  the  slow  growth  of 
such  tumor  gives  long  security  to  the  integument  covering  it;  its 
firm  and  resistant  texture  enables  it  to  withstand  violence  which 
would  disintegrate  the  encephaloid  tumor;  nevertheless,  its  malig- 
nant character  is  incontestable,  being  shown  in  the  frequency  of 
recurrence  after  the  removal  of  such  tumor. 

The  fourth  species  of  sarcoma  is  the  myeloid,  which  is  con- 
stituted mainly  of  the  giant-cells  already  mentioned;  besides, 
there  are  intermingled  with  these  the  embryonic  cells,  a  compo- 
sition similar  to  that  which  is  revealed  by  the  microscope  in  fcetal 
marrow.  This  species  is  situated  always  adjacent  to  or  in  bone 
tissue,  and  originates  from  the  medullary  tissue  of  the  bone; 
starting  from  the  marrow,  it  grows  at  the  ex})ense  of  the  bone. 
In  this  tumor  either  the  small  or  the  giant  cell  may  predominate 
in  development;  and  when  the  small  cells  are  the  leading  pro- 
ductive factors,  then  the  tumor  has  a  rapid  course,  and  soon 
attains  large  dimensions;  but  when  the  giant  cell  is  the  predomi- 
nating element,  then  the  growth  is  tardy,  and  the  life  of  the 
tumor  is  a  long  one.  The  myeloid  sarcoma  occurs  oftenest  in  the 
head,  especially  in  the  maxillary  bones;  but  it  appears  also  in 
the  long  bones,  especially  in  the  tibia  and  femur,  oftenest  in  the 
head  of  the  tibia.  It  has  a  tendency  to  undergo  a  vascular 
transformation;  and  in  that  event,  the  development  of  vessels 
may  proceed  to  such  extent  that  the  pulsatile  movement  of  the 
tumor  is  perceptible  to  the  touch.  When  the  tumor  has  under- 
gone this  structural  change,  it  is  liable  to  be  mistaken  for  an 
aneurism.  This  mistake  may  be  made  when  the  tumor  is  seated 
on  the  leg  or  thigh,  and  is  in  proximity  to  the  vessels  of  the  limb. 
But  if  remote  from  vessels,  the  case  can  at  once  be  decided  to  be 
one  of  vascular  myeloid  sarcoma. 

Writers  disagree  concerning  the  degree  of  malignancy  of  this 
form  of  sarcoma.  Gross  estimates  that  it  passes  from  its  primary 
seat  and  becomes  constitutional  in  one -eighth  of  the  cases;  other 
surgeons  have  seen  generalization  less  frequently;  and  after 
removal  of  the  myeloid  sarcoma,  they  have  seldom  seen  recur- 
rence. 


MALIGNANT    GROWTHS.  ,  127 

There  have  been  described  other  forms  of  sarcoma;  these, 
however,  are  histologically  so  cognate  to  some  of  the  former  above 
described,  that  a  description  of  them  here  may  be  omitted, 
excejDt  the  species  known  as  melanotic,  of  which  the  malignant 
nature  commends  its  study  to  the  surgeon. 

The  melanotic  sarcoma,  as  its  name  implies,  is  dark  or  black 
in  color,  and  owes  its  hue  to  the  deposition  of  granulated  pigment 
in  the  component  cells.  The  minute  components  of  this  dark 
material  are  fusiform  or  rounded  in  form;  and  the  remaining 
constituent  cells  of  the  tumor  are  either  round  or  fusiform  in 
shape,  that  is,  similar  to  those  of  the  normal  sarcoma;  as  a  rule, 
the  si)indle-cells  exceed  the  round  ones  in  number,  so  much  so 
that  the  tumor  is  usually  fasciculated  in  structure.  The  pig- 
ment is  not  due  to  an  accidental  effusion  of  blood  into  the  growth, 
but  it  is  formed  in  the  sarcomatous  cells,  first  around  the  nuclei, 
and  then  it  enters  the  nuclei,  and  finally  appears  in  every  part  of 
the  cell. 

The  melanotic  sarcoma  is  soft  in  consistence;  and  it  appears 
especially  in  the  eye,  and  in  the  dermal  and  muscular  tissues; 
and  in  its  work  of  generalization  and  destruction,  it  stands  in  the 
front  rank  of  malignant  growths. 

The  above  description  contains  in  an  epitomized  form  the 
prominent  points  in  the  history  of  sarcoma;  in  more  elaborate  de- 
tail the  subject  may  be  found  in  the  voluminous  chapters  wdiicli 
surgical  writers  have  devoted  to  the  matter.  It  must  be  acknowl- 
edged, however,  that  the  grouping  of  the  different  species  together 
is  arbitrary,  and  that  the  relationship  between  them  is  a  con- 
strained one.  The  incongruity  of  placing  together  things  so 
diverse  has  led  some  writers  to  drop  the  name  sarcoma,  and  to 
apply  to  these  tumors  the  name  of  fibro-plastic  growths.  Though 
there  is  something  rational  in  this  proposal,  yet  the  term  sarcoma, 
stripped  as  it  now  is  of  the  irrelevancies  which  surrounded  it  in 
the  older  writers'  minds,  has  so  firm  a  place  in  surgical  Pathology 
that  it  seems  proper  to  leave  it  undisturbed  as  a  prominent  sec- 
tion of  malignant  new  growths. 

When  compared  with  epithelial  cancer,  sarcoma  was  formerly 
deemed  peculiar  to  youth  and  early  adult  life,  while  the  advent 
of  the  former  was  referred  to  more  advanced  years;  the  bloom  of 
youth  was  associated  with  sarcoma,  while  carcinoma  and  epithe- 
lioma were  deemed  the  evils  of  wasted  age;  though  this,  in  a  meas- 
ure, be  true,  yet  a  wider  observation  of  sarcoma  has  shown  that 
its  advent  may  be  in  both  3^outli  and  age,  though  it  occurs  oftener 
in  the  young. 


128  AFFECTIONS    OF    THE   s^CAET. 

When  sarcoma  and  carcinoma  are  compared  in  reference  to 
curability,  the  former  has  advantages  over  the  latter;  for  after 
pro})er  surgical  treatment  the  patient  of  sarcoma  is  less  apt  to 
have  a  recurrence  of  the  disease;  and  sliould  there  be  a  recur- 
rence, the  sarcoma  reappears  with  less  violent  character  than  is 
the  case  when  carcinoma  recurs  after  removal.  If  carcinoma 
reappears  after  excision,  abstention  from  interference,  as  a  rule, 
is  wisdom;  but  if  removed  sarcoma  reappears,  there  is  a  fair  pros- 
pect that  benefit  will  be  reaped  from  another  operation. 

In  the  treatment  of  sarcoma,  constitutional  treatment  has 
proved  of  little  avail;  however,  in  this  field  internal  medication 
has  not  had  a  fair  trial.  The  author  has  hope  that  the  future  con- 
tains some  happy  surprises,  and  that  some  day  will  witness  the 
discovery  of  remedies  which  will  check  the  growth  of,  and  finally 
extinguish,  the  malignant  tumor.  Man  with  his  innumerable 
ailments  is,  doubtless,  surrounded  by  countless  remedies,  the 
most  of  which  as  yet  are  unknown;  a  condition  of  things  des- 
tined to  change  when  greater  progress  has  been  made  in  the 
knowledge  of  materia  medica.  And  there  is  ground  for  encour- 
agement when  one  recalls  what  has  been  done  elsewhere  in  the 
therapeutic  field. 

To  turn  attention  for  a  moment  to  what  has  been  done  in 
recent  years,  nothing  can  strike  the  medical  mind  with  more 
gratifying  effect  than  the  story  of  coal  tar,  whence  chemistry  has 
extracted  so  many  remedial  agents.  Who  knows  but  that  in 
some  material  now  deemed  useless,  a  remedy  against  the  malig- 
nant growth  may  be  found?  Perhaps  the  agent  which  is  destined 
to  replace  the  present  destructive  treatment  of  the  malignant 
neoplasm  is  to  be  found  in  the  field  of  botany,  and  that  some 
simple  plant  not  even  adorned  with  flowers,  is  elaborating  the 
organic  compound  which  can  accomplish  the  great  work,  and  is 
only  waiting  the  advent  of  the  fortunate  one  who  shall  discover 
it.  In  the  innumerable  family  of  plants  the  author  has  no  doul)t 
but  that  such  a  boon  exists,  and  which,  when  found,  as  a  gift  to 
suffering  humanity  must  take  rank  alongside  of  the  discovery  of 
ansesthetics.  Though  as  yet  such  remedy  exists  only  in  enthu- 
siastic hope,  yet  the  unfortunate  victim  of  malignant  tumor  is 
not  without  some  aid  from  internal  medication;  for  it  has  been 
learned  by  observation  that,  though  certain  therapeutic  agents 
do  not  directly  possess  a  resolvent  action,  yet  they  are  able  to 
retard  growth;  as  such  may  be  mentioned  mercury,  iodine,  and 
arsenic.     Mercury  is  more  active  when  combined  with  iodine,  in 


MALIGNANT    GROWTHS.  129 

the  form  of  the  protioclide  or  deutiodide  of  mercury.  Of  the  pro- 
tiodide,  a  half  grain  may  he  given  three  times  a  day.  And  in 
such  amount  it  can  be  given  for  a  number  of  weeks;  meantime, 
its  action  should  be  carefully  watched,  and  should  symptoms  of 
phyalism  supervene,  as  may  be  found  in  the  weak  and  cachectic, 
then  the  remedy  should  be  temporarily  suspended.  Arsenic  may 
also  be  tried,  and  in  the  form  of  Fowler's  solution  of  the  arsenite 
of  potash,  five  drops  may  be  given  three  times  a  day;  and  this 
dose  should  be  increased  in  amount,  one  drop  daily,  until  as 
large  a  dose  is  reached  as  the  patient  can  tolerate.  From  the 
well-known  jjroperty  of  arsenic  of  acting  on  tlie  skin,  it  is  proba- 
ble that  it  will  act  more  efficiently  on  the  dermal  sarcomatous 
tumor.  And,  again,  as  its  effect  is  only  obtained  after  prolonged 
administration,  it  is  presumable  that  its  beneficial  action  is  bet- 
ter suited  to  tumors  of  slow  growth. 
.  Besides  the  use  of  these  remedies  taken  into  the  alimentary 
canal,  they  may  be  employed  parenchymatously,  that  is  by  direct 
injection  into  the  tumor;  thus  one  may  employ  Fowler's  solu- 
tion, or  a  solution  of  mercury  and  iodine  known  as  the  iodohy- 
drargyrate  of  potassium;  of  either  of  the  solutions  mentioned  there 
may  be  injected  with  a  hypodermic  syringe  from  four  to  eight 
drops  daily;  the  best  action  is  gotten  by  injecting  not  more  than 
two  drojDS  at  one  point,  for  if  more  be  thrown  in,  the  resulting 
irritation  is  apt  to  be  so  severe  as  to  cause  suppuration.  In  this 
work  a  syringe  with  very  fine  point  should  be  emploj^ed,  and 
care  should  be  taken  that  the  point  should  be  shar^)  and  clean. 
Besides  the  solutions  mentioned,  one  may  use  ergotine  or  the 
tincture  of  iodine;  the  latter  is  the  preferable  agent.  The  surgeon 
should  be  careful  to  insert  the  syringe  point  into  a  new  place  for 
each  injection.  Also,  the  point  should  pierce  to  different  depths 
in  order  to  bring  the  solution  into  all  portions  of  the  tumor. 
And  should  suppuration  be  excited,  the  work  of  injection  should 
be  suspended  for  some  time,  and  when  resumed  again,  it  should 
be  at  a  point  as  distant  as  possible  from  the  site  of  recent  selection. 
The  author  urges  a  persevering  trial  in  this  method  of  hypodermic 
treatment  of  the  sarcoma;  if  only  a  retardation  of  growth  is 
accomplished,  this  is  a  valuable  gain. 

Should  the  means  detailed  fail  to  effect  a  cure,  then  a  resort 
must  be  had  to  the  radical  methods  of  cauterization  or  excision. 
To  accomplish  anything  with  caustics,  the  most  potent  ones 
must  be  chosen,  as  the  chloride  of  zinc  or  potassa  fusa,  preferably 
the  latter.     To  use  this,  the  surface  of  the  tumor,  if  not  opened, 


130  AFFECTIONS    OF    THP:    SCALP. 

should  be  abraided,  since  the  epiderm  offers  some  barriers  to  the 
action  of  the  escharotic.  When  the  surface  is  opened,  then  a  wall 
of  adhesive  plaster  should  be  built  around  the  part,  so  as  to  pre- 
vent the  destruction  of  the  adjacent  sound  parts.  The  caustic 
[•otash  should  be  mixed  with  an  equal  part  of  Pulvis  Radicis 
Sanguinariie,  and  of  this  a  layer  equal  to  a  line  in  depth  should 
be  placed  on  the  tumor,  and  retained  there  by  a  covering  of  lint 
and  adhesive  plaster.  This  amount  used  will  destroy  much 
more  than  a  line's  depth  of  the  growth.  The  destroyed  part 
must  be  detached  by  means  of  moist  warmth.  Proceeding  in 
this  manner,  successive  strata  may  be  destroyed  until  the  tumor 
is  destroyed.  A  serious  obstacle  in  the  way  of  this  work  is  the 
peril  of  opening  vessels,  which  may  bleed;  and  hence  where 
large  vessels  underlie  the  tumor,  the  escharotic  must  be  used 
with  caution  or  wholly  omitted.  This  plan  always  causes  a 
large  wound,  which  will  be  tedious  in  closing.  In  the  patient, 
however,  whose  shyness  of  cutting  quite  excludes  the  scalpel, 
this  method  may  be  tried;  and  if  the  tumor  be  small  and  readily 
accessible,  with  no  adjacent  vessels  which  niay  be  imperiled, 
there  is  a  reasonable  hope  of  thus  eradicating  the  tumor. 

The  use  of  the  knife,  as  a  rule,  is  a  much  surer  and  speedier 
method,  and  by  it  the  patient  will  be  spared  much  pain  of  which 
he  is  the  victim  when  escliarotics  are  used.  The  great  misfor- 
tune of  most  patients  is,  however,  that  blatant  charlatanism  has 
implanted  in  their  minds  the  belief  that  the  cancer  quack  (or 
quackess)  possesses  for  his  relief  some  means  of  cure  unknown  to 
the  rest  of  the  world.  This  false  notion  has  such  a  hold  in  the 
popular  mind  that  intelligent  medicine  tlius  far  has  availed 
little  towards  its  removal.  The  eti'orts  of  our  profession  to  pro- 
tect the  public  from  the  cancer-harpy  are  misconstrued;  and 
hence  medical  legislation  has  accomplished  but  little;  the  vermin, 
against  whom  its  acts  are  directed,  continue  to  tiirive  and  pursue 
their  work  of  villainous  imposture. 

If  the  victim  of  the  sarcomatous  growth  escapes  the  pitfalls  of 
charlatanism,  and  coniides  his  life  to  conscientious  medicine, 
then  the  latter  may  choose  for  treatment  between  the  escharotics 
detailed,  or  the  use  of  the  knife.  In  cases  in  which  the  growth  is 
sui)erficial,  the  escharotic  })lan  should  be  preferred,  especially 
when  an  extensive  surface  is  the  site  of  the  disease;  but  when  the 
tumor  admits  of  circumscription  and  ready  removal  with  the 
scalpel,  then  the  latter  should  bo  used.  And  on  the  scalp,  where 
Ave  are  supposing  the  growth  to  be  situated,  then  the  work  should 


EPITHELIOMA.  131 

be  SO  done  as  to  avoid  conspicuous  scarring.  The  work  then 
done  must  conform  to  those  already  given  for  the  extirj^ation  of 
benign  neoplasms  on  the  head.  The  form  of  the  wound  should, 
as  far  as  possible,  be  so  made  that  the  breach  can  be  closed,  or  if 
not  closed,  reduced  to  the  smallest  size. 

Epithelioma. — This  growth  until  recent  times  was  'ill  under- 
stood, and,  like  sarcoma,  it  received  different  names  from  those 
who  wrote  concerning  it;  thus,  among  the  old  writers,  one  finds 
the  terms  noli  me  tangere,  cancerous  ulcer,  rodent  ulcer,  cutaneous 
cancer,  etc.,  names  which  plainly  meant  the  same  thing.  The  use 
of  the  microscope,  which  introduced  more  precision  in  our  knowl- 
edge of  sound  and  morbid  tissues,  though  it  threw  light  on  the  struc- 
ture indicated  by  these  names,  yet  it  did  not  lessen  the  nomen- 
clature of  the  subject;  for  example,  such  names  as  the  following 
have  been  introduced:  false  cancer,  bastard  cancer,  cancroid, 
epithelial  cancer,  and  epithelioma;  and  there  is  appropriateness 
in  the  latter  name,  when  the  fact  is  recalled  that  the  histological 
components  of  the  growth  are  epithelial  cells. 

Epithelioma  consists  of  an  infiltration  into  the  tissues  of  the 
affected  part  of  epithelial  elements  which  resemble  the  cells  on 
the  surface  of  the  skin,  or  mucous  membranes.  The  growth 
beo'ins  as  an  insig-nificant  elevation  of  the  surface,  on  which  the 
normal  covering  is  thickened;  yet  finally,  as  the  growth  increases, 
the  surface  opens,  and  continues  open  as  an  unhealing  ulcer. 
The  covering  of  the  epithelioma  before  opening  is  comj)osed  of 
numerous  strata  of  cells,  which  individuall}^  have  a  marked 
resemblance  to  cells  investing  the  adjacent  unaffected  parts;  on 
the  face  or  scalp  tliey  are  similar  to  the  normal  epidermal  cells. 
In  the  progress  of  the  growth,  the  cellular  elements  grow  both 
outwards  and  inwards;  and  it  is  in  the  encroachment  of  these 
cells  on  the  subjacent  structures,  sinking  into  and  infiltrating 
these  structures,  that  we  have  the  distinguishing  characteristics  of 
the  epithelioma. 

The  cells  are  small  when  compared  with  those  of  carcinoma; 
they  are  nucleated  and  lie  in  layers  or  spheroidal  masses  which 
can  be  squeezed  from  the  affected  structure.  These  rounded 
masses  when  placed  in  water,  though  they  may  swell,  do  not  dis- 
solve or  readily  break  down,  but  swim  as  separate  particles.  In 
consequence  of  the  form  of  the  follicles  or  depressions  in  the 
structures  in  which  these  cellular  masses  lie,  the  cells  are  often 
arranged  in  a  rounded  or  imbricated  manner;  and  if  these  be 
divided  in  a  certain  direction,  the  appearance  under  the  micro- 


132  AFFKCTIONS    OF    THE    SCALP. 

scope  is  that  of  a  bird's  nest,  or  a  fl(n'al  whorl.  As  this  wliorl-like 
form  is  common  to  the  normal  (]e[)ressions  of  the  skin  and  mucous 
membrane,  care  must  be  taken  not  to  confound  the  normal  with 
the  abnormal  forms.  The  youtliful  microscopist  often  finds  bird's 
nests,  which  are  normal  structures  of  nature  and  contain  no 
element  of  disease. 

Epithelioma  commences  on  the  surface  and  may  be  designated 
a  superficial  disease;  yet,  as  it  spreads  on  the  surface,  it  finally 
penetrates  inwards,  and  then  causes  extensive  destruction  of  the 
tissues.  The  ulcerated  field  which  is  produced  is  irregular  or 
winding  in  its  boundary,  and  uneven  or  nodulated  in  its  surface. 
From  such  a  wound  there  is  discharged  a  thin  viscid  fluid  which 
is  neither  ])us  nor  pure  serum,  yet  it  is  similar  to  the  latter.  This 
open  surface  is  of  a  reddish  gray  color;  it  has  no  tendency  to 
granulate;  and  if  wounded  it  does  not  bleed  freely,  thus  differing 
from  granulative  tissue.  If  this  diseased  structure  be  examined, 
by  the  touch,  it  will  be  characterized  b}^  induration;  both  the 
floor  and  border  are  unnaturally  hard.  Before  opening  and 
afterwards,  the  affected  part  is  coherent,  so  that  it  can  readily  be 
taken  between  the  fingers,  and  moved  on  the  parts  on  which  it 
rests.  This  mobility  is  an  important  characteristic  of  epithelioma ; 
and  when  duly  estimated  it  will  aid  the  surgeon  in  distinguishing 
this  lesion  from  a  chronic  ulcer. 

In  its  primary  stage  there  are  three  forms  in  which  epithe- 
lioma presents  itself:  papillary,  nodulated,  and  squamous. 

In  the  papillary  mode  of  origin,  the  disease  begins  by  the 
enlargement  of  one  or  more  cutaneous  jjapilla?;  as  the  papilla 
enlarges,  it  becomes  ensheathed  in  a  coat  of  epithelial  material. 
If  the  growth  commence  by  one  papilla,  others  soon  appear 
around  this  one;  these  have  a  red  or  grayish  color,  and  around 
the  affected  part,  there  may  be  observed  dilated  capillaries.  This 
form  is  seen  oftenest  on  the  back  of  the  hand  and  the  lower  lip. 

The  second  primary  mode  of  appearance,  somewliat  cognate 
to  the  preceding,  is  in  the  form  of  a  tuber  or  nodule;  and  this 
enlargement  may  vary  from  the  size  of  a  small  pea  to  that  of  a 
walnut,  the  greater  form  arising  from  the  enlargement  of  a 
smaller  one,  or  from  the  fusion  of  two  or  more  smaller  ones. 
This  growth  is  usually  irregular  on  its  surface;  and  hence  the  des- 
ignation of  lobulated  epithelioma,  by  which  it  isoften  distinguished. 
In  such  a  nodule  one  finds  sudoriparous  and  sebaceous  glands; 
the  latter  are  tiie  most  conspicuous;  in  fact,  they  furnish  a  cliar- 
acteristic  of  the  nodulated  epithelioma;   for  if  the  structure  be 


EPITHELIOMA.  133 

pressed,  from  the  clefts  on  its  surface  there  may  be  forced  out 
particles  of  sebaceous  material,  mingled  with  epithelial  detritus. 
This  growth  as  a  rule  is  sessile  on  the  part  whence  it  arises,  and, 
exceptionally,  it  is  pedunculated.  The  author  has  seen  a  case  in 
which  around  the  original  nodule  smaller  ones  were  present, 
separated  by  small  spaces  of  the  unaffected  structure. 

In  the  third  or  scpiamous  variety,  the  first  sign  of  the 
epithelioma  is  a  small  gray  or  dark-colored  scale,  a  line  or  less  in 
diameter,  and  which  seems  as  if  set  in  a  casing  of  sound  epidermal 
structure.  This  scale  can  be  detached ;  and  the  patient,  as  a  rule, 
falls  into  the  unfortunate  habit  of  loosening  and  detaching  it  with 
his  finger  nail.  This  constant  irritation  of  the  part  promotes  the 
development  of  the  disease,  and  is  entitled  to  the  name  of  a 
causal  factor. 

The  papillary  species  occur  oftenest  around  the  mouth, 
especially  in  the  lower  lip.  The  nodulated  form  is  less  common, 
and  has,  as  special  site,  mucous  and  semi-mucous  surfaces  of  the 
genitalia.  The  squamous  form  is  so  closely  allied  to  lupus  that 
ihey  may  be  regarded  as  akin  or,  possibly,  identical  structures. 
This  form  appears  on  the  cheeks,  nose,  forehead  and  temporal 
region.  It  may  occur  on  the  scalp  which  has  become  denuded 
of  hair.  Depressed  dermal  vitality  disposes  to  its  origin  and 
subsequent  development.  The  initial  scale  consists  of  altered 
epidermal  material;  and  by  its  adherence,  it  becomes  a  local 
irritant  of  the  part,  and  interferes  with  nutrition  at  that  jDoint. 
This  form  develops  and  grows  slowly,  and,  as  a  rule,  it  penetrates 
but  little  beneath  the  surface;  its  growth  is  principally  through 
peripheral  extension,  the  morbid  work  being  limited  to  the  skin; 
exceptionally,  the  superficial  epithelioma  may  change  its  type, 
and,  having  become  carcinomatous  in  character,  it  then  penetrates 
inwards  and  attacks  indifferently  any  tissue  which  may  be  in  its 
way.  Thus  the  author  has  seen  skin,  adeps,  muscle  and  bone 
desiroyed  by  an  epithelioma,  whicli,  having  begun  as  a  simple 
squamoas  afi'ection  of  the  skin  of  the  cheek,  penetrated  to  and 
attacked  the  superior  maxilla.  The  patient  attributed  his  affec- 
tion to  the  mischievous  habit  which  he  had  acquired  of  constantly 
detaching  a  scab  from  the  malar  region  of  the  face. 

A  distinguishing  characteristic  of  epithelial  cancer  is  that  it 
continues  a  purely  local  disease  for  a  long  time.  In  many  cases 
the  affection  does  not  attack  the  glands;  glandular  affection 
occurs  oftenest  when  the  epithelioma  is  seated  on  the  lower  lip, 
parotidean  and  genital  regions.     Secondary  or  glandular  infection 


134  VFP^KCTIONS    OF    THE    SCALP. 

from  epithelioma  seated  on  the  hp  or  cheek  occurs  in  glands  sit- 
uated near  the  submaxillary  gland.  Such  infected  gland  gradu- 
ally enlarges,  and,  for  a  time,  it  is  freely  movable;  later,  the  gland 
contracts  adhesions  to  the  parts  around  it,  and  while  thus  mova- 
ble, the  removal  of  the  gland  may  not  be  followed  by  a  reappear- 
ance of  the  disease.  But  if  the  gland  is  fastened  to  the  parts 
around  so  that  it  cannot  be  easily  enucleated,  then  the  removal 
affords  no  guaranty  against  an  early  recurrence. 

For  a  period  during  the  enlargement  of  the  gland,  its  struc- 
ture presents  a  uniform  consistence;  and  this  consistence  is  less 
hrm  than  that  of  those  parts  which  have  undergone  induration 
through  the  advancing  disease.  The  gland  will  continue  to 
enlarge  until  it  has  reached  a  volume  of  an  inch  or  more  in 
diameter;  then  it  softens  in  the  center,  and  opens  at  some  point 
of  its  surface;  and  this  opening  continues  through  the  overlying 
j)arts  until  it  pierces  through  the  skin.  Through  the  opening 
thus  formed,  there  is  discharged  a  semi-liquid  material  composed 
of  the  disintegrated  gland  and  serum;  this  is  not  pus,  but  an 
emulsion  of  softened  glandular  material  and  serum.  This  stage 
of  secondary  metastatic  development  having  been  reached,  the 
disease  progresses  rapidly;  the  parts  contiguous  to  the  disinte- 
grating gland  become  hardened,  and  afterwards  break  down. 
The  affected  part  is  then  swollen,  and  presents  a  number  of 
ragged  openings,  from  which  there  is  a  constant  discharge  of  the 
emulsified  material  mentioned,  often  tinged  with  blood.  Where 
the  glands  of  the  neck  have  become  secondarily  affected,  and  the 
structures  break  down,  not  unfrequently  the  blood-vessels  are 
opened  and  luemorrhage  ensues:  death  has  often  thus  occurred  at 
a  period  much  earlier  in  the  disease  than  otherwise  would  have 
happened. 

The  course  of  the  disea-se  on  the  skin  is  always  slow;  on  the 
semi-mucous  surfaces  it  is  more  rapid;  ami  on  the  mucous  sur- 
faces the  disease,  in  its  progress  and  evolution,  is  still  more  s[)eedy 
in  its  course. 

Besides  the  implication  of  glands  contiguous  or  near,  in  rare 
instances,  the  disease  appears  in  some  remote  organ  or  part  of  the 
body;  thus  cancer  of  the  liver  or  stomach  may  follow  an  epithe- 
lioma on  the  head. 

This  growth  is  oftenest  seen  in  those  who  have  passed  the 
vital  meridian:  namely,  in  those  who  are  over  forty  years  of  age. 
Sex  is  an  important  factor;  the  growth  occurs  much  oftener  in 
men   than   in  women;   the  male  is  three   times  more   liable  to 


EPITHELIOMA.  135 

epithelioma  than  the  female.  This  probably  depends  on  the  fact 
that  the  disease  originates  usually  in  the  skin,  which,  in  the  male, 
is  more  exposed  to  injury  than  that  of  the  female.  Likewise,  the 
greater  abundance  of  epithelial  elements  at  certain  points  in  the 
skin  of  the  male,  may  render  his  skin  a  more  fertile  field  for  the 
origin  of  epithelioma.  The  lack  of  cleanliness  among  the  poor 
is  assigned  as  a  reason  for  the  more  frequent  appearance  of 
the  disease  among  that  class,  and  the  greater  want  of  cleanliness 
in  the  male,  explains  the  more  frequent  occurrence  of  the  disease 
among  men. 

The  opinion  has  been  expressed  by  a  few  writers  who  have 
studied  the  causation  of  epithelioma,  that  it  originates  from  a 
microphyte.  A  reason  urged  for  this  is  that  the  growth  oftenest 
commences  where  there  is  a  lesion  or  breach  favorable  to  the 
implantation  and  preservation  of  such  jDarasite.  As  yet,  however, 
such  an  agent  has  not  been  discovered,  and  the  suggestion  that 
this  disease  is  of  a  parasitic  nature  is  as  yet  a  speculative  deduc- 
tion based  on  the  tendency  of  modern  Pathology  to  find,  or  think 
to  find,  in  the  microphyte  the  universal  cause  of  disease. 

Treatment. — This  is  best  done  by  external  or  surgical  means, 
though  within  the  last  few  years  an  attempt  has  been  made  to 
cure  it  by  the  employment  of  internal  remedies.  For  this  pur- 
pose the  chlorate  of  potassium  has  been  praised ;  cures  are 
claimed  to  have  been  obtained  by  this  remedy.  For  this  pur- 
pose commence  with  small  doses,  as  for  example,  five  grain 
three  times  daily,  and  increase  the  amount  until  as  much  as  as 
half  drachm  is  taken  within  twenty-four  hours.  In  case  the 
growth  has  opened,  and  an  ulcerated  surface  is  present,  then  a 
solution  may  be  made  of  the  salt,  and  applied  externally  by 
means  of  lint.  To  accomplish  anything  with  this  treatment,  it 
must  be  continued  for  a  long  time.  The  author  has  made  trial 
of  this  plan  of  treatment,  but  with  only  doubtful  results.  But 
since  a  doubtful  treatment  is  more  satisfactory  to  the  patient 
than  forlorn  expectance,  hence,  in  cases  in  which  the  disease  is 
so  situated  as  to  be  inaccessible  to  external  treatment,  this 
remedy  might  be  used.  Another  remedy  which  deserves 
trial  is  arsenic.  As  this  remedy  has  been  demonstrated  to 
have  a  curative  action  in  squamous  disease  of  the  skin,  from 
analogy,  a  beneficial  action  from  it  miglit  be  expected  in  epithe- 
lioma of  the  squamous  species.  Fowler's  solution  is  the  best 
form  for  use:  commence  with  three  drops  of  this,  three  times 
daily,  and  increase  the  dose  one  drop  each  day,  until  the  stom- 


13G  AFFECTIONS    OF    TH  K    SCALP. 

ach  will  not  tolerate  a  larger  amount;  tlieu  gradually  lessen 
the  amount  until  a  small  dose  is  reached.  Thus  by  ascent 
and  descent  in  the  quantity  given,  a  large  amount  of  arsenic 
can  be  safely  administered.  This  agent  may  be  used  where 
the  disease  is  inaccessible  to  local  means;  also,  it  may  be  given 
in  cases  in  w^hich  an  operation  has  been  performed,  as  a 
jtrophylactic  against  recurrence.  Chrysophanic  acid,  whicii  has 
recently  gained  much  celebrity  as  a  remedy  against  skin  disease, 
might  be  tried  in  epithelioma;  for  this  purpose  it  may  be  used 
externally.  As  it  has  recently  been  given  internally  in  psoriasis, 
so  it  might  be  given  in  a  similar  manner  in  epithelioma;  for  this 
purpose,  very  small  doses  should  be  used,  since  the  strength  of 
the  medicine  has  not  been  definitely  determined. 

A  more  direct  way  of  using  these  agents  of  internal  medica- 
tion would  be  through  liypodermic  injection;  in  this  Avay  the 
author  has  tried  Fowler's  solution;  also  the  solution  of  ihe 
muriate  of  lime,  which  is  a  useful  agent,  when  given  internally, 
against  neoplasms.  To  use  these  remedies,  the  syringe  point  is 
to  be  introduced  into  the  growth  at  several  points,  and  not  more 
than  two  drops  injected  at  each  point;  a  larger  amount  might 
cause  local  death  and  breaking  down  of  the  tissues,  and  thus 
defeat  the  purpose  of  inducing  atro})liic  change  of  the  morbid 
tissue.  The  author  has  made  trial  of  several  agents  in  the 
manner  mentioned,  and,  from  the  results  gotten,  he  gives  the 
preference  to  the  arsenical  solution.  The  hypodermic  treat- 
ment of  ei)ithelioma  is  a  field  which  invites  further  trial,  and 
it  gives  promise  of  furnishing  weapons  against  this  disease, 
especially  in  cases  which  have  been  operated  on,  and  in  wliicli 
there  has  been  recurrence  in  such  form  that  an  operation  is  not 
practicable. 

Tiiough  considerable  has  been  said  in  favor  of  medication, 
internal  and  hypodermic,  yet  the  practice  and  observation  of  the 
author  have  taught  him  that  of  all  the  means  of  treatment,  the 
knife  or,  its  equivalent,  the  scissors,  is  the  most  eff'ective  one.  The 
fear  of,  or  j^opular  prejudice  against,  the  use  of  the  surgeon's  instru- 
ment, has  caused  the  loss  of  manv  a  life.  This  fear,  planted  by 
the  charlatan's  hand;  has  been  carefully  cultivated  by  him,  for  it 
is  in  this  section  of  disease  that  the  conscienceless  montebank 
plies  his  villainous  craft,  and  reaps  his  richest  harvest.  The 
result  is  that  often  when  the  patient  applies  to  the  surgeon,  the 
disease  has  made  such  advances  under  the  torturing  methods  of 
the  charlatan,  that  the  latter  is  forced  to  cease  his  caustic  mutila- 


EPITHELIOMA.  137 

tion;  and,  at  the  same  time,  there  is  left  to  the  surgeon  no  oppor- 
tunity of  using  the  scalpel,  for  the  disease,  in  such  a  case,  has  so 
intrenched  itself  in  the  patient's  body  that  it  holds  equal  posses- 
sion with  life  itself.  In  such  unfortunate  position,  the  surgeon 
usually  errs  in  operative  interference,  and  he  does  better  if  he 
limits  his  work  to  internal  and  hypodermic  medication. 

Should,  however,  the  patient  shun  the  snares  in  which  he  is 
so  often  entrapped  by  charlatanism,  and  consult  the  surgeon 
at  an  early  period,  then  the  growth  should  be  removed  with 
knife  or  scissors.  As  an  important  preliminary  to  the  work  of 
excision,  the  implicated  surface  must  be  carefully  looked  at,  and 
the  extent  of  the  affected  structures  be  determined,  as  nearly  as 
possible,  with  the  unaided  eye.  In  the  act  of  looking,  it  is  seldom 
that  the  eye  is  permitted  or  made  to  see  all  that  it  is  possible  to 
see.  In  the  work  of  vision,  the  eye  falls  into  the  habit  of  over- 
looking much  that  lies  within  the  field  of  vision;  in  fact,  this  is 
requisite  to  the  conservation  of  sight;  for,  if  the  eye  were  forced 
to  continually  give  close  attention  to  all  that  lies  before  it,  the 
task  would  be  painful,  indeed,  it  would  soon  become  intolerable, 
and  the  overtaxed  organ  would  soon  be  overpowered  and  no 
longer  able  to  act.  This  conservative  act  of  inattentive  vision, 
so  needful  for  healthful  function,  soon  becomes  our  wonted  habit, 
and  must  be  studiously  avoided  when  it  is  necessary  to  study  all 
the  features,  lines  and  external  appearances  of  an  object.  Sight 
must  be  so  employed  as  not  only  to  take  in  the  superficial  exten- 
sion of  what  is  observed,  but  with  equal  thoroughness,  the  eye 
should  penetrate  and  seize,  in  the  logical  meaning  of  the  word, 
the  intension  of  what  is  seen. 

In  the  study  of  a  surface,  the  site  of  an  epithelioma,  aided  as 
well  as  unaided  vision  should  cooperate  in  the  work.  To  aid  the 
eye  a  hand  microscope  of  slightly  magnifying  jDower  should  be 
used;,  thus  enlarged  papillse  are  discovered,  which  otherwise 
would  have  escaped  detection.  Vision  in  these  ways  having 
made  its  best  search,  the  finger  must  next  do  its  duty  in  the  way 
of  examining  tactilely  the  surface,  and  also  be  made  to  explore  the 
structure  beneath  the  surface.  The  surface  must  be  lightly  taken 
between  the  fingers,  and  any  abnormal  hardness  must  be  noted. 
Such  hardness  is  discovered  by  comj)aring  the  density  of  the 
adjacent  sound  parts  with  those  afiected;  thus  the  gradual  tran- 
sition from  normal  to  abnormal  structure  may  be  found.  At  the 
time  that  the  local  conditions  are  thus  being  studied,  the  adjacent 
glands  should  be  examined,  and  anv  inclination  to  enlargement 
10 


138  AFFECTIONS    OF    THE   SCALP. 

in  them  carefully  noted;  for  such  enlargement  means  that  the 
alfection  has  outlived  its  local  period  of  development,  and  has 
already  made  one  great  stride  towards  generalization. 

The  extent  of  surface  and  structure  involved  in  the  growth 
having  been  accurately  determined,  the  operator  should  mark 
the  boundaries  with  a  tinting  pencil;  or,  what  is  better,  tliis 
tracing  can  be  done  with  a  pencil  of  nitrate  of  silver,  a  few 
hours  before  the  cutting  is  to  be  done.  The  work  of  preliminary 
tracing  is  one  of  great  importance,  and  though  it  may  obstruct 
the  manual  freedom  of  the  operator,  and  render  his  work  some- 
what tedious,  yet  the  patient  is  a  great  gainer  thereby.  The 
laurels  won  by  celerity  are  too  often  dimmed  by  an  early  recur- 
rence ;  it  is  here,  as  often  occurs  elsewhere,  that  the  painstaking 
plodder  is  the  final  victor.  As  before  said,  a  tinted  line,  pre- 
viously traced,  must  serve  as  a  path  to  the  knife,  and  the  work 
to  be  effective  must  be  done  early.  Then  the  sacrifice  of  the 
tissues  is  so  small  that  the  wound  can  usually  be  closed,  espe- 
cially where  the  tissues  can  be  slidden,  or  laterally  displaced.  The 
cut  edges  then  should  be  perpendicular;  or  if  they  be  made 
slopingly,  then  tlie  two  should  be  so  cut  that  they  will  rest  on 
each  other  in  accurate  coaptation,  so  that  when  the  sutures  are 
introduced  the  closure  will  be  complete,  and  no  gaps  or  interlying 
vacuoles  will  be  left  to  delay  healing.  Thus  done,  early  healing 
without  scarring  will  be  obtained  ;  yet  scarring  must  be  reckoned 
as  a  subordinate  incident  in  the  removal  of  an  epithelioma,  for 
the  removal  must  be  complete  and  uns})aring  of  tissue. 

After  the  excision  of  the  affected  structures,  the  cut  surfaces 
of  the  latter  must  be  carefully  examined,  in  order  to  ascertain 
whether  the  cutting  has  been  done  through  sound  tissue;  the 
examination  can  be  more  readily  made  on  this  than  on  the 
bleeding  surface  of  the  parts  whence  the  growth  has  been 
removed.  The  excised  part  being  washed,  it  can  easily  be  seen 
whether  the  entirety  of  the  growth  has  been  removed ;  if  it  has 
been  completely  done,  then  close  the  wound,  or  dress  it  open,  as 
the  conditions  permit.  But  if  there  be  found  suspicious  tissue  in 
the  removed  part,  then  the  cutting  must  extend  further,  until 
thoroughly  sound  tissue  has  been  reached.  As  before  directed, 
the  nearest  lymphatic  glands  should  be  carefully  palpated,  and 
if  evidences  of  disease  are  found  in  tliem,  the  operation  must  be 
directed  to  these  structures;  each  enlarged  gland  must  be  re- 
moved. At  an  early  period  the  glands  can  be  easily  enucleated; 
but  later,  they  contract  adhesion  to  the  contiguous  parts,  and  the 


CARCIXOMA.  139 

extirpation  is  a  more  tedious  task.  When,  such  adhesion  is 
found,  along  with  the  gland,  some  of  the  surrounding  adherent 
tissue  should  also  be  excised.  Such  fixation  with  adherence  of 
the  glands  is  always  of  ominous  portent;  and  in  such  case,  to 
guard  against  recurrence,  the  parts  suspected  of  infection  should 
be  unsparingly  sacrificed.  And  even  these  precautions  are 
usually  unavailing,  for  adjacent  glandular  implication  means 
general  infection.  In  such  cases  internal  medication  with  arsenic 
should  be  rigorously  pursued;  thus  the  patient,  if  not  cured,  is, 
at  least,  solaced  with  hope  of  relief. 

Where  the  growth  lies  externally  and  is  so  situated  that  com- 
plete excision  is  impossible,  then  among  the  means  of  attacking 
it  is  the  use  of  destructive  escharotics,  viz.,  the  potential  or  actual 
cautery;  of  the  former,  one  of  the  most  effective  is  a  compound 
of  potassa  fusa  already  spoken  of  In  this  way  deep  sections  of 
the  growth  can  successfully  be  removed.  The  ascertained  virtue 
of  arsenic  in  cutaneous  disease  would  point  to  its  probable  utilit}^ 
used  as  a  caustic,  in  dermal  epithelioma.  For  this  purpose  an 
excellent  compound  is  that  consisting  of  equal  parts  of  arsenious 
acid  and  cinnabar.  This  trustworthy  escharotic,  however,  must 
be  applied  cautiously,  lest  it  act  as  a  poison;  hence,  but  limited 
sections  of  surface  should  be  successively  attacked.  When  the 
disease  lies  in  a  mucous  surface,  then  heat  in  the  form  of  the 
galvanic  cautery  or  ferrum  candens  may  be  used. 

Carcinoma. — Carcinoma  and  cancer,  equivalent  names,  derived 
respectively  from  the  Greek  and  Latin  tongues,  have  reference  to 
the  form  of  the  diseased  part,  or  to  the  appearance  of  the  vessels 
which  lie  like  radii  diverging  from  the  part;  more  probably, 
however,  the  name  has  reference  to  the  firm  hold  with  which 
this  growth  clings  to  its  unfortunate  subject.  With  Celsus  the 
name  cancer  was  applied  to  mortification  or  death  of  the  soft 
parts,  a  meaning  far  remote  from  the  modern  signification  of  the 
word.  A  term  cognate  to  cancer  is  scirrhus,  which  has  reference 
to  the  induration  commonly  found  in  cancerous  structures.  For 
a  century  or  more  the  term  cancer  has  been  used  to  denote  malig- 
nant growths  of  a  destructive  tendency.  This  term  was  vaguely 
and  indefinitely  used  until  the  beginning  of  this  century,  when 
•Bichat  carried  the  study  of  disease  from  the  crude  mass  to  the 
constituent  tissues  of  diseased  parts.  Bichat  classified  morbid 
changes  of  structure  under  two  heads:  general  alteration  or 
change,  and  particular  alteration  or  change.  According  to  him, 
the  affections  in  which  general  alteration  is  seen  are  inflamma- 
tion and  scirrhus. 


140  AFFECTIONS    OF    TIIK    SCALP, 

That  the  name  cancer  was  obscurely  used  is  shown  in  John 
Hunter's  remark  that  the  diseases  wliich  are  chissified  as  cancer- 
ous are  dilferent  in  appearance  and  probably  differ  in  their 
nature.     Yet  Hunter  left  these  differences  unexplained. 

Early  in  the  nineteenth  century  the  notion  was  held,  that,  in 
the  malignant  growth,  elements  exist  which  cannot  be  found 
elsewhere  in  tlie  normal  or  unaffected  ])arts,  and  thus  a  broad 
distinction  was  established  between  the  benign  and  malignant 
growths.  And  thonee  arose  tlio  classification  of  hoteroloo-ous  and 
homologous  tumors,  as  synonymous  with  malignant  and  benign. 
The  peculiar  element  of  cancer  was  particularly  isolated  by 
Cruveilliier,  who,  in  cutting  a  cancerous  tumor  and  scjueezing  it, 
obtained  the  heterologous  elements  in  the  expressed  fluid.  This 
fluid  examined  microscopically  presents  small  bodies,  some  of 
which  are  definitely  formed,  and  others  shapeless  or  irregular. 
This  fluid,  or  emulsion,  as  it  might  be  named,  can  not  be 
derived  from  a  benign  growth.  Thus  an  advance  was  made 
in  the  knowledge  of  cancer;  and  further,  cancerous  tissue  was 
found  to  consist  of  an  areolar,  mesh-like,  or  connective  frame- 
work; and  this  framework  contained  the  fluid  in  wliich  were 
discovered  cells  of  a  peculiar  form,  which  were  nametl  cancer- 
cells.  These  cells,  according  to  Lebcrt,  Broca  and  others,  have 
peculiar  characteristics,  differing  fi-oni  any  other  cells  found 
among  the  component  elements  of  the  body,  and  which,  when 
seen,  justify  the  observer  in  declaring  that  they  are  of  malignant 
nature;  and,  from  not  occurring  in  normal  tissue,  such  cells  are 
named  heterologous.  After  further  study  of  the  subject,  Lebert 
has  been  forced  to  admit  that,  from  the  observation  of  the  cell 
alone,  one  is  not  justified  in  declaring  that  it  is  of  cancerous 
origin.  But  if  the  tissue  containing  tlie  cells  be  given,  then  a 
microscopic  inspection  of  its  structure  will  enable  the  observer  to 
declare  that  tlie  case  is,  or  is  not,  one  of  cancer. 

Virchow,  who  has  studied  the  cellular  components  of  tumors, 
asserts  that  there  is  no  cell  peculiar  to,  or  characteristic  of,  cancer; 
in  fact,  that  the  cancer  cell  should  not  be  named  heterologous 
or  heteromor])hous,  since  it  is  identical  with  other  normal  cells. 
Virchow  pronounces  the  cell  of  cancer  identical  with  cells  con- 
stituting epithelium;  and  where  a  difference  from  epithelial 
cells  occurs  in  cancerous  structure,  it  is  due  to  some  accidental  cir- 
cumstance in  the  growth  of  the  cell.  Virchow  finds  that  cancer- 
ous structure  consists  of  a  stroma  of  new-formed  tissue,  originat- 
ing from  preexisting  connective  tissue,  which  is  arranged  in  an 


CARCINOMA.  141 

areolar  or  sponge-like  form ;  and  the  minute  spaces  or  vacuoles 
in  this  stroma  are  filled  with  a  cream-like  emulsion,  the  succus 
cancri;  and  an  examination  of  this  fluid  reveals  cells  which 
are  similar  to  normal  epithelial  cells.  This  cancerous  tissue 
resembles  that  of  epithelioma,  the  difference  being  that  in  the 
latter  there  is  no  new-formed  connective  tissue  stromj^. 

According  to  the  foregoing  opinion  of  Virchow,  and  which  is 
concurred  in  by  others,  there  is  no  specific  cell  which  can  be 
declared  cancerous,  since  the  cell  which  is  found  in  cancer  occurs 
also  in  normal  tissue;  it  is  sometimes  absent  in  the  structure  of 
tumors  which  are  certainly  cancerous,  and  it  can  occur  in  tumors 
which  are  neither  scirrhoid  nor  encephaloid  in  type. 

As  there  is  no  cell  peculiar  to  cancer,  so  there  is  no  single  or 
isolated  pathological  form  which  can  be  pronounced  to  be  typical 
of  cancer;  in  fact,  under  the  head  of  malignant  growths,  there  ex- 
ists a  great  variety  of  tumors  which  have  some  analogies  with  each 
other,  yet,  also,  offer  many  points  of  unlikeness,  and  these  points 
of  unlikeness  are  so  numerous  that  Robin  has  proposed  to  drop 
the  name  of  cancer,  and  to  study  each  individual  growth  sepa- 
rately. Though  this  might  be  justifiable,  yet  it  would  greatly 
embarrass  both  student  and  practitioner  in  their  respective  tasks 

It  being,  then,  impossible  to  formulate  a  definition  of  cancer 
founded  on  its  microscopical  appearances  and  anatomical  form, 
a  resort  has  next  been  had  to  the  clinical  history  or  course  which 
the  tumor  follows  from  its  commencement  to  its  final  ending. 
Such  a  history, ^briefly  traced,  runs  somewhat  as  follows:  Cancer 
begins  as  hardened  tissue,  at  first  of  small  or  insignificant  vol- 
ume, for  a  long  time  painless,  and,  hence,  for  a  time  unobserved; 
it  grows  continuously,  and  when  it  attains  some  size,  it  may  cause 
some  inconvenience  or  pains  of  a  shooting  character;  its  bounda- 
ries are  rarely  uniform  or  regular;  it  ma}^  arise  in  every  structure 
of  the  body,  yet  it  oftener  originates  in  glandular  structures,  and 
oftener  in  those  which  lie  near  the  external  surface  of  the  body, 
the  disease  seeming  to  prefer  as  site,  parts  which  are  the  scene  of 
much  functional  activity,  or  those  which  are  in  incessant  vibra- 
tion between  inaction  and  action  ;  the  tumor,  by  increase  of  vol- 
ume, encroaches  on,  and  finally  destroys,  parts  around  and  over 
it,  and  its  development  is  only  impeded,  and  at  length  arrested, 
through  an  insufficient  supply  of  nutrient  material  on  one  side, 
and  through  the  escape  and  loss  of  the  same  through  the  opening 
or  ulcerated  breach  which  finally  appears  in  the  tumor.  The 
patient   nearly  always   refers  to  some  local    injury  of  the  part 


142  AFKECTIOX;?    OK    THE    SCALP. 

wliicli  was  tlie  starting  point  of  the  cancer,  and  the  connection 
between  such  lesion  and  the  growth  is  so  clearly  traceable  that 
it  is  safe  to  conclude  that  some  traumatic  agency  is,  if  not  always, 
at  least  usually,  the  exciting  cause  of  cancer.  The  last  act  in  this 
eventful  history,  Avhen  the  growth  is  unrestrained  in  its  develop- 
ment, is  ajways  death,  which  is  preceded  by  infection  of  the 
contiguous  glands,  and,  afterwards,  the  disease  appears  in  the 
more  remote  parts  of  tlie  body.  This  generalization  seems  to 
take  place  through  the  medium  of  the  lymphatics  and  blood 
vessels. 

As  has  been  stated,  in  the  microscopic  study  of  cancer,  two 
leading  constituents  have  been  found,  viz.,  the  areolar  framework 
and  the  so-called  cancer  cells  contained  in  this  framework.  In 
any  given  cancerous  growth  these  two  constituents  may  exist  in 
very  different  proportions;  the  framework  can  be  greatly  in 
excess,  and  so  can  the  cellular  elements.  In  the  former  case,  the 
growth  is  remarkable  for  its  hard  and  firm  structure,  and  this 
form  is  named  scirrhus.  Where  the  cellular  elements  are  the 
chief  constituent,  then  the  tumor  is  named  encephaloid.  This 
name  is  derived  from  the  resemblance  of  the  structure  to  the  sub- 
stance of  the  brain;  and,  as  Avill  be  recalled,  this  name,  for  similar 
reasons,  is  used  to  designate  a  species  of  sarcoma. 

The  scirrhous  and  the  encephaloid  types  were  the  ones  which 
first  attracted  the  attention  of  the  early  observers.  The  error 
existed  for  a  long  time  of  considering  scirrhus  as  the  j^rimary 
form,  and  encephaloid  cancer  as  the  direct  derivative  from  the 
former,  through,  some  powers  of  softening,  for  which  no  satisfac- 
tory explanation  could  be  offered.  It  soon  became  apparent  that 
they  were  separate  species,  being  distinctly  different  structures 
from  their  earliest  commencement ;  their  histories  having  nothing 
in  common,  except  that  each  one  ended  in  the  death  of  the 
patient.  Scirrhus,  however,  develops  slowly,  and  presents,  later 
in  its  course,  signs  of  regressive  action,  or  an  effort  at  healing  in 
the  oldest  portions  of  the  tumor;  that  is,  both  stroma  and  con- 
tained cells  seem  to  have  reached  their  maturity,  and  are  found 
in  a  stage  of  degeneration  and  decay.  And  to  this  is  due  the 
scar-like  depression  often  found  over  this  form  of  cancer;  and 
when  the  disease  is  limited  to  the  skin  in  the  lenticular  form, 
such  retraction  explains  the  irregularity  of  surface.  The  enceph- 
aloid type  is  soft  and  commonly  of  a  uniform  rounded  outline. 
It  is  soft,  so  much  so  that  it  has  often  been  mistaken  for  a  lipoma, 
or  a  collection  of  pus.     It  is  of  very  rapid  development,  especially 


.   CARCINOMA.  143 

where  it  has  recurred  after  an  operation.  Tliis  type  examined 
microscopically  is  found  to  consist  of  an  areolar  stroma  and  cells; 
the  cells  are  the  j^i'edominant  constituent;  and  to  the  small 
amount  of  stroma  is  due  the  characteristic  softness  of  this  kind 
of  cancer.  Glandular  infection  also  follows  this,  yet  the  tumor 
may  attain  considerable  dimensions  before  the  glands  are  impli- 
cated. As  to  the  primary  point  of  commencement,  encephaloid 
cancer  begins  oftenest  in  the  testicle;  according  to  Paget's  obser- 
vation, it  is  found  there  in  one-third  of  the  cases  of  cancerous 
testicle.  This  organ,  as  the  author  has  seen  in  three  cases,  may 
be  attacked  in  early  childhood.  It  attacks  also,  not  unfrequently, 
the  bones.     It  is  remarkable  for  the  rapidity  of  its  fatal  march. 

Though  carcinoma  is  constituted  mainly  of  the  constituents 
mentioned,  yet  other  elements  may  be  added,  and  give  a  special 
character  to  the  tumor;  and  to  this  is  due  the  great  confusion 
among  writers  who  have  written  on  the  subject  of  cancer;  and  it 
was  on  this  account  that  Robin  and  others  proposed  to  relegate 
the  term  cancer  to  the  historic  past,  and  to  describe  separately 
each  form  of  malignant  disease:  to  extricate  himself  from  the 
difficulties  of  such  a  method,  Robin  was  forced  to  adopt  some 
generic  name:  he  chose  that  of  epithelioma;  and  thus  his 
would-be  improvement  in  nomenclature  amounted  to  no  more 
than  a  substitution  of  terms.  Through  the  addition  of  pigmen- 
tary material  to  the  two  fundamental  elements  of  carcinoma, 
melanotic  cancer  arises.  And  by  the  addition  of  colloid  or 
gelatinous  matter,  there  arises  a  peculiar  form  named  colloid 
cancer,  which  has  been  a  puzzle  to  the  pathologist;  and,  as  yet, 
the  origin  of  this  jelly-like  material  is  a  subject  of  investigation. 
To  say  that  it  arises  from  a  liquefaction  of  the  solid  components 
of  the  growth,  throws  darkness  rather  than  light  over  the  prob- 
lem. In  another  form  of  cancer  there  is  found  cartilaginous 
material,  and  which  may  be  in  such  quantity  as  to  conceal  the 
true  nature  of  the  growth  for  a  time.  Beside  the  malignant  car- 
tilaginous tumor  there  is  one  which  is  benign,  and  which  has 
neither  tendency  to  ulceration  nor  generalization;  this  form  is 
hard  and  has  a  tendency  to  ossify,  while  the  malignant  species  is 
softer,  and  tends  to  change  to  a  semi-liquid  or  pulp-like  material. 
This  soft  chondroid  form  of  cancer  tends  to  generalization,  and 
is  very  malignant.  In  another  form  of  tumor,  to  the  dual  pri- 
mary components,  elements  of  bone  may  be  added,  and  thus  a 
tumor  of  extreme  hardness  is  formed,  to  which  the  name  of  oste- 
oid cancer  is  applied.     Thus  besides  the  two    typical  forms  of 


144  AFFECTIONS   OF    THE    SCALP. 

scirrhous  and  eiicephaloid  cancer,  through  superadded  elements 
four  other  forms  have  arisen,  bearing  the  names  melanotic,  col- 
loid, clioudroid  and  osteoid  cancer,  the  name  being  derived  froni 
the  new  element  which  has  been  added. 

Besides  the  forms  of  carcinoma  which  have  been  mentioned, 
the  disease  may  appear  in  the  site  whence  a  benign  growtli  has 
been  removed.  Again,  a  growth  has  forsaken  its  simpler  type  of 
an  epithelioma  or  sarcoma  and  appeared  as  a  species  of  cancer. 
To  attempt  an  explanation  of  such  transmutation  in  the  present 
state  of  our  knowledge  would  be  fruitless. 

Cancer  is  of  infrequent  occurrence  on  the  seal]);  still  it  does 
occur  here;  one  of  the  worst  cases  of  the  disease  ever  seen  by  the 
author  was  in  the  scalp.  This  was  concealed  by  the  patient  for 
a  long  time.  Commencing  as  a  small  nodule,  the  disease  of 
encephaloid  type  developed  into  a  tumor  of  large  volume;  this 
attacked  the  cranium,  finally  destroying  almost  the  entirety  of 
one  i^arietal  bone,  and  extensively  exposed  one  hemisphere  of 
the  brain.  The  brain  was  never  attacked,  and  for  a  long  time 
the  mind  remained  unimpaired;  later,  mental  perversion  ap- 
peared in  which  there  was  a  slight  excitation  of  the  faculties, 
similar  to  the  excitement  from  wine.  This  extensive  destruction 
of  the  soft  parts  and  cranial  wall  was  attended  by  only  a  small 
degree  of  pain.  During  the  last  few  weeks,  the  chief  complaint 
of  the  patient  was  from  fatigue.  Meantime,  the  hopes  of  recover}'' 
were  cherished  by  her,  and  plans  for  the  future  made  by  the 
j)atient,  though  an  extensive  surface  of  one  hemisphere  lay 
exposed  to  view.  In  this  case,  there  is  probability  that  a  cure 
could  have  been  effected  had  an  early  operation  been  done;  for 
the  history  showed  that,  for  a  long  period,  the  disease  existed  as  a 
small  wartdike  nodule,  which,  for  a  time,  was  concealed  by  so 
dressing  the  hair  as  to  cover  the  growth. 

Treatment. — Cancer  may  be  treated  by  internal  means,  by  top- 
ical applications,  and  by  means  which  slowly  destroy  or  at  once 
directly  remove,  the  part. 

Internal  medication  has  been  industriously  pursued;  and,  at 
different  periods,  the  much-sought-for  agent  has  been  announced 
as  actually  discovered.  A  reference  to  the  old  books  on  JNIateria 
Medica  will  present  the  reader,  under  the  head  of  Anodynes  and 
Narcotics,  a  number  of  agents  for  which  there  was  claimed  a  cur- 
ative agency  against  cancer;  conspicuous  among  these  are  aconite, 
conium,  stramonium  and  hyoscyamus.  These  agents  have  failed 
to  do  that  which  was  claimed  for  them.     In  the  use  of  these  med- 


PXEUMATOCEPHALUS.  145 

icaiits,  as  well  as  of  others,  it  is  probable  that  a  satisfactory  trial 
has  not  been  made  of  them:  they  have  been  administered  too 
late,  in  insufficient  amount,  or  for  too  brief  a  time.  As  the 
disease  is  sometimes  met  when  it  has  reached  a  stage  that  forbids 
operative  interference,  when  the  case  of  the  ph^^sician  is  limited 
to  work  in  which  but  little  result  can  be  expected,  and  what  he 
attempts  is  with  the  view  that  aliquid  fecisse  videatur:  then  these 
remedies  may  be  retried,  and  besides  those  mentioned,  a  trial 
should  be  made  of  arsenic  and  iodine.  And  if  the  tumor  is 
opened  through  ulceration,  then  some  of  these  remedies  may  be 
used  topically. 

Treatment  by  cauterization,  actual  and  potential,  has  fre- 
quently been  tried;  and  if  it  be  decided  to  make  use  of  some  of 
these  methods,  then  the  work  may  be  done  in  accordance  with 
plans  which  have  been  described  in  the  treatment  of  sarcoma 
and  epithelioma.  Though  these  methods  deserve  mention  and 
occasional  trial,  yet  of  all  plans  of  treatment,  a  resort  to  excision, 
in  which  the  knife  is  used  early  and  radically,  promises  the  best 
results;  and  the  manner  of  doing  such  excision  has  been  generally 
indicated  in  a  preceding  section  in  which  the  writer  described 
the  treatment  of  sarcoma. 

Instead  of  assuming  the  exuberant  growth  presented  in  the 
case  just  mentioned,  cancerous  disease  when  seated  in  the  scalp 
commonly  approaches  to  epithelioma  in  type.  For  besides  the 
six  varieties  of  carcinoma  which  have  been  cited,  there  are  others; 
and  among  the  latter  are  those  which  so  closely  resemble  epithe- 
lioma that  it  is  difficult  to  establish  a  clear  distinction.  Nature, 
in  the  domain  of  both  normal  and  abnormal  products,  is  often  a 
fugitive  from  both  law  and  rule;  she  has  infinite  resources 
whereby  she  can  indulge  in  continuous  variation.  The  surgeon, 
as  well  as  the  practitioner  of  medicine,  daily  meets  proof  of  what 
is  here  stated,  and  must  take  due  account  of  them  if  he  attain 
success  in  his  practical  work.  The  one  who  uses  well  his  eyes 
and  remembers  what  he  sees,  even  though  he  has  not  fathomed 
the  utmost  depths  of  Pathology,  often  becomes  successful  in  the 
p/actice  of  his  art. 

Pneumatocephalus. — Beneath  the  anterior  and  posterior  por- 
tions of  the  scalp  there  sometimes  occurs  a  singular  tumor,  of 
which  the  content  is 'air.  Thomas,  of  Tours,  a  pioneer  in  the 
observation  of  this  development,  was  struck  by  its  sonorous  char- 
acter. This  tumor  when  seated  behind,  over  the  mastoid  region, 
receives  its  air  from  the  mastoid  cells  or  antrum,  of  which  the 


14G  AFFECTION'S    oF    TIIF    SCALP. 

outer  wall  from  congenital  defect,  or  eroding  disease,  is  open,  and 
permits  the  air,  received  from  the  middle  ear,  to  escape  beneatli 
the  scalp;  and  this  air  finds  isolated  lodgment  there.  It  does  not 
insinuate  itself  irregularly  in  the  structure  of  the  scalp,  as  is  seen 
in  empliN'sema,  in  which  air  has  escaped  from  the  air-passages 
and  diffused  itself  in  the  adjacent  or  overlying  soft  parts.  The 
air,  in  tne  case  under  consideration,  is  contained  in  a  common 
cavity.  Besides  in  the  mastoid  region,  such  air  tumor  has  been 
observed  on  the  forehead,  where  air  is  derived  from,  and  com- 
municates with,  the  frontal  sinus,  which,  congenitally  or  acci- 
dentally, lias  been  opened  and  permitted  the  air  from  the  nasal 
passage  to  enter  and  remain.  Such  emphysematous  tumor  has 
received  the  name  of  pneumatocephalus.  An  explanation  offered 
of  the  commencement  of  such  tumor  is  that  in  violent  expulsive 
efforts  from  tlie  lungs,  when  the  mouth  and  nostrils  are  closed, 
or  partly  closed,  the  compressed  air  escapes  from  the  nasal  passages 
through  the  middle  ear  and  unclosed  mastoid  antrum  beneath  the 
covering  scalp;  or  should  there  be  an  imperfection  in  the  outer  wall 
of  the  frontal  sinus,  the  air  may  find  escape  there,  and  the  result 
be  a  pneumatocephalous  development,  lying  on  the  corresponding 
side  of  the  forehead.  A  diagnostic  sign  in  each  case  would  be 
that  the  tumor  could  be  reduced  in  volume  by  pressure,  viz.,  its 
air  content  could  be  forced  from  it,  and  the  tumor  thus  made  to 
vanish.  And  to  further  verify  the  true  nature  of  the  tumor,  a 
testing  puncture  might  be  made  with  a  hj'podermic  syringe. 

This  air  tumor,  if  let  alone,  would  never  endanger  the  pa- 
tient's life.  It  is  simply  an  annoyance  to  him  through  its  conspic- 
uous volume,  or,  perhaps,  it  may  interfere  with  the  dress  of  the 
head.  Should  treatment  be  decided  on,  two  ways  are  open,  viz., 
a  simply  conservative  one,  and  a  radical  one.  As  conservative 
treatment,  there  niay  be  made  simple  compression  over  the  tumor 
by  means  of  a  pad,  which  is  retained  in  site  by  means  of  straps 
and  buckles.  Or  a  more  radical  plan  would  be  to  lay  oi)en  the 
cavity  and  dissect  off  its  parietal  surfaces,  so  that  the  walls,  so 
denuded,  might  be  brought  together  in  such  a  way  that  by  their 
coalescence  the  cavity  would  be  occluded,  and  no  space  be  left  in 
which  air  might  •  collect.  For  some  time  afterward,  pressure 
should  be  made  over  the  part,  so  as  to  guard  against  a  recurrence 
of  the  tumor.  This  case,  however,  like  inany  others,  is  one  in 
which  the  prudent  surgeon  would  rarely  interfere,  since  such 
interference  is  not  free  from  peril.  It  can  readily  be  seen  that 
inflammatory  action  mio;ht  th3re  be  awakened  in  the  mastoid 


PXEUMATOCEPHALUS;    PEEICRANIUM.  147 

cells  in  case  of  a  pneumatocele  over  that  region;  and  once  appear- 
ing there,  the  inflammation  might  readily  enter  the  cranial 
cavity  and  attack  the  encephalon.  Hence  surgical  effort  should 
be  limited  to  simple  compression,  as  above  mentioned.  Should 
the  prurigo  secandi  tonnent  the  young,  or  the  conscienceless  old 
surgeon,  he  maybe  assured  that  this  is  an  ill  field  for  such  adven- 
ture; too  near  intrusion  is  forbidden  to  the  household  of  life  situ- 
ated close  by;  the  mariner  does  not  carelessly  trifle  with  the 
wooden  wall  which  distinguishes  (separates)  him  from  death. 

Pericranium  and  Its  Affections. — The  lowermost  layer  of  the^ 
scalp  is  the  pericranium,  or  periosteum  of  the  cranium,  which  is 
rather  a  dependence  of  the  subjacent  bone  than  of  the  overlying 
scalp.  This  structure,  closely  allied  to  periosteal  tissue  elsewhere 
has  already  been  briefly  referred  to.  Though  loosely  adherent  to 
the  skull  except  where  it  is  inserted  into  the  sutures,  yet  the 
•attachment  is  sufficiently  intimate  between  this  membrane  and 
the  skull  to  permit  of  disease  or  lesion  being  often  shared  in  com- 
mon by  them.  And  the  same  applies  to  the  soft  parts  which  lie 
exterior  to  the  pericranium.  Yet  it  is  the  site  of  isolated  injury 
and  disease,  which  we  now  proceed  to  consider. 

Wounds. — Deep  wounds  of  the  scalp  necessarily  iniplicate  the 
pericranium;  the  treatment  of  such  does  not  differ  from  that 
already  detailed.  But  especial  care  should  be  taken  to  cover  the 
bone,  for  exposure  of  bone  to  the  air,  or  prolonged  contact  of  the 
same  with  the  detritus  or  excreta  of  a  wound,  ends  in  death  of 
the  bone  so  exposed;  and  such  necrosis  greatly  prolongs  the 
time  of  healing,  since  weeks  and  even  months  are  required  to 
complete  the  exfoliation  of  the  dead  surface,  so  that  the  part  can 
close.  The  attempt  to  shorten  this  time  may  be  made  through 
erasion  or  exsection  of  the  necrosing  bone;  yet  such  attempt  is 
usually  fruitless,  since  the  surgeon's  instrument  will  never  follow 
the  line  which  nature  selects  for  the  line  of  detachment.  Indeed, 
the  exsecting  chisel  in  the  author's  hand  has  seemingly  prolonged 
the  time  of  healing,  since  the  new  surface  made,  sometimes, 
exfoliated.  To  remedy  necrosis,  then,  in  case  of  a  wound  expos- 
ing the  skull,  after  scrupulous  antisepsis,  close  the  wound  so  as  to 
cover  the  bone. 

There  may  be  an  unopened  wound  consisting  of  simple  detach- 
ment of  the  pericranium  from  the  skull;  and  such  separation 
may  be  so  slight  as  to  be  insignificant,  or  it  may  be  very  exten- 
sive; in  the  latter  case  there  might  occur  some  effusion  of  blood 
beneath  the  pericranium.     Yet  such   effusion  would  not  equal 


148  AFFKCTIONS    OF    THE    SCALP. 

that  which  can  occur  in  the  space  of  lax  tissue  just  outside  of  the 
pericranium;  liii-morrhage  here  can  be  excessive,  while  that 
beneath  the  pericranium  is  of  limited  amount.  It  could  only  be 
in  large  rjuantity  in  a  case  in  which  the  pericranium  was  torn  so 
that  an  intercommunication  was  established  between  the  space 
beneath  with  that  outside  of  the  pericraniun).  In  such  cases  a 
mild,  conservative  treatment  is  indicated;  only  where  the  blood 
is  effused  in  excessive  quantity  would  it  be  proper  to  evacuate  it. 
Simple  compression,  if  properly  anil  patiently  employed,  will 
di.ssipate  the  blood. 

The  mo.st  frequent  affection  of  cranial  periosteum  is  inflam- 
mation, which  may  be  local  or  general;  and  this  may  be  of  an 
acute  or  chronic  type.  Local  as  well  as  general  periostitis  may 
be  the  sequent  of  some  affection  of  the  overlying  scalp.  For  exam- 
ple, it  may  arise  from  an  abscess,  ulcer,  or  wound;  it  is  frequently 
of  syphilitic  origin.  Scrofula  and  rheumatism  are  occasiona4 
causes  of  it 

From  whatever  cause  the  periostitis  arises,  the  usual  con- 
ditions of  inflammation  are  present;  of  these  the  most  important 
is  proliferation,  or  cell-growth,  in  the  affected  structure.  Thence 
ihere  is  thickening.  This  cell  growth  may  be  absorbed,  and  then 
the  membrane  returns  to  its  normal  condition.  Or  the  new  cel- 
lular elements  may  undergo  organization  and  become  added  to 
the  periosteum,  and  cause  permanent  thickening.  Such  an 
event  is  rarely  a  source  of  trouble  to  the  patient.  Another  event 
is  osteal  growth,  in  which  the  new  material  is  converted  into 
bone.  Such  bony  growth  appears  in  laminated,  spinous,  or  irreg- 
ular form;  and  it  is  attached  to  the  external  plate  of  the  cranium, 
and  remains  as  a  permanent  addition  to  the  same.  Such  devel- 
opment is  named  an  osteophyte  or  bone  growth;  the  term  exostosis 
is  also  applicable  to  it.  It  is  seldom  so  large  as  to  become  a 
source  of  trouble;  and  it  could  only  become  so  when  it  arises  as  a 
sharp  spine,  or  thorn-like  process  pricking  the  parts  which  rest 
on  it.  In  fijit  or  laminated  form  it  would  be  wholly  witliout 
action  on  the  superjacent  parts.  Where  the  growth  is  of  sharp 
spine  form,  then  it  should  be  excised,  as  it  became  necessary  in  a 
case  .seen  by  the  author  in  which  the  offending  growth  was  situ- 
ated on  the  upper  and  lateral  part  of  the  occipital  bone.  After 
exposing  the  growth  it  was  exsected,  and  the  wound  treated  as  a 
simple  one.     The  complete  healing  was  tedious. 

Periostitis  may  assume  on  the  cranium,  as  elsewhere,  a  differ- 
ent form.     The  inflammatorv  action  in  some  cases  is  confined 


CRANIAL    PERIOSTITIS.  149 

chiefly  to  the  outer  structures  of  the  pericranium;  but  in  others 
it  chiefly  attacks  the  deeper  layer;  and  the  course  will  difl'er  in 
the  two  cases;  for  if  the  inflammation  is  chiefly  in  the  deeper 
texture  of  the  periosteum,  then  its  march  will  be  trammeled  by 
the  sutural  adhesions.  On  the  outer  face  there  is  no  such  limita- 
tion; the  disease  spreads  rapidl}^  over  a  larger  part  of  the  pericra- 
nium. This  diffuse  periostitis  quickly  ends  in  suppuration;  the 
pus  formed  rapidly  diffuses  itself  beneath  or  ujDon  the  pericranium. 
When  outside,  the  diffusion  may  be  so  extensive  that  a  large  part 
of  the  overlying  scalp  may  be  uplifted  by  purulent  fluid. 

In  the  early  stage  of  periostitis,  the  most  efficient  agent  to 
check  the  inflammation  is  iodine.  The  action  of  this  agent  is 
obtained  when  it  is  applied  externally,  in  tlie  form  of  the  tincture 
or  ointment  of  iodine.  The  iodide  of  potassium  may  likewise  be 
given,  in  dose  of  ten  grains,  three  times  daily.  By  this  treatment, 
both  in  local  and  general  pericranitis,  suppuration  may  be  averted, 
or  greatly  limited.  But  when  pus  has  formed,  it  should  be 
evacuated  by  one  or  more  incisions;  several  openings  will  be 
required  when  the  pus  is  widely  diffused.  And  through  the 
openings  there  made,  an  antiseptic  fluid  should  be  freely  injected. 
This  may  be  a  sublimated  solution,  or  iodized  solution,  or  one  of 
chloride  of  sodium.  Along  with  the  pus,  fllamentous  shreds  of 
dead  tissue  will  also  be  detached  and  discharged.  If  such  shreds 
are  not  fully  detached,  violent  traction  should  not  be  made  on 
them,  since  such  pulling  may  open  vessels  which  may  bleed  and 
retard  the  healing.  The  work  of  opening  should  be  done  early, 
since  then  the  destruction  of  tissue  is  lessened.  In  the  worst 
cases  of  diffuse  suppuration,  sections  of  the  scalp  die;  and  then, 
after  recovery,  some  deformity  will  remain.  When  the  pus  lies 
for  a  time  in  contact  with  the  outer  face  of  the  skull,  some  necrosis 
ensues,  and  the  healing  will  be  retarded.  In  such  cases  the  outer 
surface  of  the  bone,  dying,  is  slowly  detached  from  the  adjacent 
sound  bone;  and  the  detachment  of  such  bone  is  best  confided  to 
nature. 

A  frequent  form  of  disease  of  the  pericranium  is  gummy 
periostitis.  Syphilis  announces  and  records  its  possession  of  the 
subject  by  various  eruptions  on  the  skin,  clearly  visible  and  legi- 
ble by  the  eye;  these  eruptions,  called  syphilides,  differ  much  from 
each  other  in  nature  and  appearance.  But  subcutaneously,  the 
disease  has  but  one  leading  characteristic,  viz.,  a  neoplastic  pro- 
duction, the  so-called  gummy  growth.  Or,  put  figuratively,  the 
syphilitic  pathological  tree  is  rich  in  fruit  of  various  hue  and 


150  AFFECTIONS   OF    THE    SCALP.  . 

form;  if  we  should  select  a  characteristic  specimen  of  these  prod- 
ucts, it  would  be  the  gummy  growth.  The  other  rashes  have 
their  non-syphilitic  analogues;  but  the  gomrae,  or  gumma,  is  an 
isolated  original,  without  correlate,  kinsman,  or  analogues  in  the 
pathological  household.  The  ])ericranial  gomme  appears  in  two 
forms,  the  circumscribed  and  the  diffused. 

The  circumscribe|l  gummy  growth  commences  in  tlie  deeper 
surface  of  the  periosteum,  and  thence  developing  and  growing 
in  conical  form,  it  presses  on  the  subjacent  bone  and  causes 
absorption  of  its  tissues;  one  has  here,  on  a  small  scale,  })rogress- 
ive  osseous  rarefaction.  The  gummy  structure,  when  of  limited 
volume,  undergoes  the  fatty  change,  and,  later,  it  is  absorbed.  If 
of  larger  volume,  the  growth  might  sup})urate  and  open  exter- 
nally. This  disappearance  by  absorption  is  the  usual  event;  and 
the  process  is  then  named  by  Virchow  syphilitic  dry  caries.  The 
site  of  such  vanished  gomme  is  indicated  by  an  irregular,  bony 
growth,  in  the  form  of  minute  plates  or  spine-like  points,  which 
circumvallate  the  depression  in  the  bone. 

The  gummy  growth  can  develop  in  diffuse  form;  it  primarily 
commences  then,  in  and  beneath  the  periosteum,  as  a  soft  ge- 
latinous structure,  which  soon  appears  as  a  pulpy  layer  of  a 
whitish  hue.  Beneath  this  the  bone  undergoes  rarefaction;  and 
in  the  spaces  opened  in  the  bone  the  gummy  material  likewise 
develops  in  nodular  or  conical  shape.  These  masses  of  gummy 
material  are  traversed  by  minute  blood-vessels  which  remain 
permeable.  The  gummy  matter  is  thus  distinguished  from 
tubercular  material,  in  which  no  vessels  are  found.  This  diffused 
form  of  gummy  periostitis  may  recede,  and  absorption  of  the 
new  material  occur;  and  then  osteophytic  growths  remain  to 
mark  the  surface.  Or  the  mass  can  suppurate,  open  and  be  elim- 
inated. The  pus  thence  evacuated  is  viscid,  and  resembles  acacia 
gum  in  solution. 

The  treatment  in  such  cases  should  be  topical  and  general. 
The  local  application  of  iodine  acts  most  satisfactorily  in  perios- 
titis arising  from  any  cause,  but  in  no  case  does  it  act  so  benefi- 
cially as  when  the  case  is  syphilitic.  Applied  either  in  the  form  of 
ointjnent  or  tincture,  it  acts  as  a  resolvent  of  the  new  growth. 
That  such  action  does  occur  has  been  proved  by  direct  observa- 
tion with  the  microscope  of  living  tissue,  to  which  iodine  had 
been  applied.  If  the  tincture  of  iodine  be  used,  then,  from  time 
to  time,  the  dried  epidermal  crust  must  be  removed,  else  such 
material  soon  becomes  an  impenetrable  obstacle  to  the  action  of 


PERICRANIUM    AND    ITS    AFFECTIONS.  151 

the  remedy;  and,  on  this  account,  the  ointment  acts  better.  This 
local  treatment  must  be  long  persevered  in,  in  order  to  obtain  the 
full  action.  Meantime  antisyphilitic  remedies  should  be  taken 
internally;  these  should  consist  of  a  combination  of  mercury  and 
iodine.  Sj^philitic  pericranitis  whether  limited  or  diffused,  treated 
early,  in  the  manner  mentioned,  will  be  made  to  recede  and 
vanish  in  most  cases.  If  the  disease  is  not  thus  checked,  but 
proceeds  to  suppuration,  the  condition  becomes  graver;  for  the 
suppurative  action  is  rarely  limited  to  the  soft  structures,  but  also 
attacks  the  adjacent  external  plate  of  the  skull  and  causes  death 
o5  the  same;  in  fact,  a  limited  portion  of  the  entire  thickness  of 
the  cranial  wall  may  then  die  and  be  detached.  And  though 
such  breach,  both  in  the  scalp  and  skull,  is  repaired  by  fibrous 
tissues,  yet  the  site  of  the  disease  is  permanently  impaired,  espe- 
cially the  bone,  which  will  never  be  restored  to  its  normal  integ- 
rity. When  the  entire  wall  is  thus  perforated,  it  is  probable  that 
there  is  likewise  similar  disease  of  the  dura  mater  lying  under- 
neath, that  is,  both  intracranial  and  extracranial  gummy  develop- 
ment. 


CHAPTER   lY. 


CRANIUM. 


Having  concluded  the  surgical  studies  of  the  scalp,  we  will  take 
up  the  cranium,  premising  with  some  general  remarks  in  regard 
to  the  form,  structure,  and  general  characteristics  of  the  skull. 
The  form  of  the  cranium  is  that  of  an  ovoid,  of  which  the  larger 
end  is  directed  backwards;  in  a  few  cases,  the  anterior  and  pos- 
terior ends  are  similar  in  extent  and  form.  The  transverse  and 
antero-posterior  diameters  may  be  nearly  equal  in  the  brachy- 
cephalic  skull;  or  the  antero-posterior  diameter  may  be  much  the 
greater,  and  the  form  is  named  the  dolicho-cephalic  skull.  The 
anterior  and  posterior  laces  may  be  rounded  or  approach  to  a 
quadrangular  form.  The  vault  of  the  skull  may  be  flatly 
rounded;  or  it  may  have  a  ridge-like  elevation  in  the  median 
line  from  before  backwards. 

The  rounded  contour  of  the  vault  of  the  cranium  is  exchanged 
below  for  a  more  irregular  and  flattened  form;  the  surface  below 
is  more  broken  and  abruptly  interrupted  than  is  the  upper  one. 
Tiie  inner  surface  of  the  skull  is  more  uneven  and  interrupted 
than  the  external  one;  this  applies  especially  to  the  base,  where 
anteriorly,  the  orbital  wings  of  the  s[)henoid,  and  behind,  the 
petrous  portions  of  the  temporal  bones,  abruptly  break  the  surface 
and  form  topographical  boundaries  of  the  parts  contained  there. 

Structurally,  crania  differ  greatly;  some  are  much  thicker 
than  others;  this  is  a  national  characteristic,  as  well  as  an  indi- 
vidual peculiarity.  From  a  limited  range  of  observation,  the 
author  ventures  to  decide;  that  those  who  labor  with  their  heads 
have  thinner  skulls  than  those  who  labor  with  their  hands.  In 
two  instances,  of  unusual  intellect,  the  tenuity  of  the  cranium, 
as  revealed  by  necropsy,  was  remarkable. 

The  cranial  vault  and  base  differ  greatly  in  regard  to  inter- 
ruption of  structure  through  canals  and  direct  openings.  Such 
interruption  is  wholly  exceptional  in  the  upper  half  of  the 
cranium. 

(  152) 


TRAUMATIC    LESIONS    OF    THE    CRANIUM.  153 

These  varieties  of  conformation,  surface,  and  of  thickness  at 
points,  or  in  totality,  have  a  direct  bearing  on,  or  relation  to, 
the  capacity  of  the  skull  to  resist  violence;  one  skull  may  suc- 
cessfully resist  violence  which  another  could  not  withstand. 

The  power  to  resist  is  influenced  by  the  sutures,  or  possibly 
is  due  to  the  inter-sutural  material.  As  is  known,  the  bones  of 
the  foetal  head  are  but  imperfectly  developed,  and  are  united  by 
sutures  which  are  also  incomplete.  This  disposition  permits  of 
the  safe  transit  of  the  foetal  head  through  the  pelvic  passage; 
without  such  arrangement,  in  most  cases  the  child's  life  would 
be  lost.  And  the  continuance  of  the  sutures  for  many  years,  also 
acts  protectively.  The  natural  fusion  of  the  cranial  bones  com- 
mences at  from  forty  to  fifty  years  of  age;  and  this  process,  called 
synostosis,  continues  through  many  years,  being,  in  the  majority 
of  cases,  only  ended  when  the  subject  has  reached  seventy  or 
eighty  years  of  age.  After  this  synostosal  fusion,  the  skull  has 
the  appearance  as  if  cast  in  one  piece,  and  it  is  much  more  fragile 
than  it  is  prior  to  such  fusion.  This  is  demonstrated  by  taking 
two  dried  skulls,  one  of  a  young  subject  and  another  of  an  old  one, 
and  allowing  them  to  fall  the  distance  of  four  feet  upon  a  stone 
pavement;  the  skull  of  the  young  subject  will  rebound  almost  to 
the  starting  point,  and  not  be  broken;  but  the  other  skull  will 
break,  and  as  it  does  so  it  yields  the  sound  of  a  broken  kettle. 
Besides  the  vanishing  of  the  sutures,  the  lessened  amount  of  the 
organic  constituents  of  the  bone  may  probably  account  for  the 
increased  fragility  of  the  bones  of  the  aged  skull. 

In  early  foetal  life  the  skull  is  a  simple  fibrous  capsule;  in  the 
subsequent  course  of  development,  cartilage  replaces  this  fibrous 
structure  in  the  lower  part  and  base;  and,  later,  this  ossifies.  On 
the  contrary,  the  parts  constituting  the  vault  directly  undergo 
ossification  without  an  intermediate  stage  of  cartilage.  And  this 
may  account  for  the  tardiness  of  repair  which  occurs  after  fracture 
of  the  vault  and  sides  of  the  skull;  months  are  required  for  recov- 
ery after  such  injury,  and  even  then  the  work  is  imperfectly  done. 
Fibrous  tissue,  and  not  bone,  is  the  medium  of  union  between 
fragments  of  the  fractured  cranium.  And  also  the  portion  of 
bone  removed  by  the  trephine  usually  remains  absent;  and  unless 
the  excised  portion  be  replaced  with  certain  precautionary  prepa- 
rations, the  breach,  in  future,  will  only  be  replaced  by  fibrous 
tissue. 

Traumatic  Lesions  of  the  Cranium. — The  cranium  may  be  the 
subject  of  contusion,  penetrating  wound,  incised  wound  and 
fracture.  11 


154  ('KANIUNf. 

Contusion  liere  originates  from  direct  viOience;  ana  it  may  be 
limited  to  a  small  surface,  or  a  considerable  extent  of  bone  may 
thus  be  implicated.  The  diagnosis  of  such  injury  is  diiiicult,  in 
fact,  impossible,  when  the  overlying  scalp  has  not  been  opened; 
and  in  such  a  case  the  contusion  nmst  be  inferred  from  the  sub- 
sequent action  of  the  injured  bone.  Tiie  contusion  consists  in  a 
derangement,  or  limited  displacement,  of  the  constituents  compos- 
ing the  bone.  The  lesional  work  does  violence  to  the  minute 
vessels  contained  in  the  bone,  and  the  circulation  of  blood 
being  disturbed  in  the  bone,  the  nutritive  processes  of  the  latter 
are  altered  and  interfered  with.  And  according  to  the  nature 
and  extent  of  the  local  nutritive  disturbances,  so  the  subsequent 
character  of  the  lesion  will  take  shape.  For  example,  if  the 
injury  is  a  slight  one,  restoration  to  perfect  integrity  will  ensue 
after  a  few  weeks.  But  if  the  violence  has  been  greater,  then 
acute  inflammation  of  the  bone  will  occur,  and,  as  a  result,  there 
may  remain  subsequently,  at  the  place,  an  increase  of  osseous 
structure;  and  this  increased  thickness  may  be  jjermanent.  And, 
finally,  the  molecular  injury  may  be  so  great  that  restitution  to 
the  former  state  is  impossible;  there  occurs  then  necrosis  of  the 
injured  part,  with  final  exfoliation  and  detachment  of  a  layer  of 
bone.  In  the  several  instances  cited,  the  contiguous  periosteum 
participated  in  the  alterations;  and  in  case  of  necrosis,  the  j^erios- 
teum  will  inflame  and  suppurate,  so  that  it  will  be  necessary  to 
incise  the  membrane  and  set  free  the  contained  pus. 

The  penetrating  wound  of  the  cranium  may  be  caused  by  a 
round  instrument  similar  to  an  awl;  or  it  may  be  caused  by  a 
sharp  blade;  or  the  injuring  instrument  may  be  angular,  as  a 
spike  or  a  nail.  If  the  instrument  be  small,  then  the  resulting 
lesion  may  consist  of  a  simple  displacement  of  tiie  substance  of 
the  bone;  and  when  the  injuring  agent  is  removed,  the  wound 
closes  partially  or  incompletely,  so  that  a  fine  probe  could  not 
j)ass  through  it.  This  closure  is  due  to  the  inherent  elasticity  of 
the  bone.  Such  penetrating  wound  may  pass  partially  or  com- 
pletely through  the  thickness  of  the  skull;  the  partially  piercing 
wound  is  not  a  dangerous  one,  while  that  which  passes  through 
the  cranial  wall  may  in  two  ways  be  dangerous;  it  may  fracture 
and  detach  a  fragment  from  the  inner  plate  of  the  skull;  and, 
secondly,  it  may  pass  still  deeper  and  wound  the  encei)halon. 
The  detached  fragment  of  the  internal  surface  of  the  skull 
becomes  an  element  of  intense  peril.  The  pulsatile  motions  of 
the  adjacent  brain  would  cause  such  piece  of  bone  to  become  a 


TRAUMATIC    LESIONS    OF    THE   CRANIUM.  155 

constant  source  of  irritation;  tliere  are  no  conditions  present 
wliicli  favor  or  allow  of  the  fragment  becoming  encysted.  The 
final  end  would  be  the  formation  of  a  pus  cavity,  which  might 
attain  great  dimensions  and  cause  extensive  destruction  of  the 
brain.  The  true  condition  in  such  a  case  might  not  be  suspected 
in  the  commencement,  since,  for  a  time,  no  symptoms  would 
manifest  it,  but  when  suppuration  occurs,  this  would  be  indicated 
by  impairment  of  some  function  of  the  brain.  Another  occasional 
complication  of  such  penetrating  wound  is  that  the  injuring 
instrument  may  break,  and  a  fragment  of  it  remain  in  the  wound. 
Such  fragment  may  protrude  beyond  the  inner  wall,  and,  remain- 
ing there,  become  a  violent  irritant  of  the  brain;  to  do  so,  the 
broken  point  must  pierce  through  and  beyond  the  dura  mater. 

Among  such  penetrating  wounds  of  the  skull  may  be  included 
those  which  enter  the  orbit,  and,  having  pierced  the  soft  parts, 
they  perforate  the  bony  wall  of  the  orbit  at  some  point,  and  enter 
the  cranial  cavity.  Such  a  wound  has  been  caused  by  a  piece  of 
wire,  a  sharp  fragment  of  hard  wood,  an  umbrella  staff,  the 
point  of  a  saber,  etc.  An  infant  of  the  royal  family  of  France  was 
killed  by  a  needle  which  was  thrust  through  the  orbit  into  the 
brain.  And  Henry  the  Second,  of  the  house  of  Valois,  was  killed 
in  a  tournament  by  a  fragment  of  a  lance  entering  his  brain 
through  the  orbit.  He  was  treated  by  Ambrose  Pare,  with  the 
great  anatomist  Vesalius  as  consultant,  both  princes  in  medicine. 
The  execution  of  four  criminals  sentenced  to  death  was  hastened, 
so  that  their  heads  might  serve  for  experimental  work  to  aid  in 
discovering  the  broken  lance  point;  yet  in  vain,  for  the  wounded 
man  died  on  the  eleventh  day. 

From  what  has  been  said  of  the  penetrating  wound  of  the 
skull,  it  is  manifest  that,  though  the  lesion  may  be  minute  in  its 
proportions,  yet  in  its  fatal  consequences  it  may  equal  in  fatality 
wounds  of  much  greater  magnitude.  The  author  has  knowledge 
of  what  seemed  to  be  an  insignificant  injury  of  this  class,  in  which 
the  small  blade  of  a  knife  was  forced  through  the  occipital  bone, 
and,  breaking  off,  the  point  remained.  For  some  days  the  man 
suffered  no  inconvenience,  then  cerebral  inflammation  developed, 
which  soon  ended  the  victim's  life.  The  necropsy  revealed  the 
broken  point  of  the  knife  fixed  in  the  skull  and  slightly  penetrat- 
ing the  surface  of  tlie  brain.  Similar  cases,  of  which  examples 
abound  in  surgery,  illustrate  the  importance  of  the  early  recogni- 
tion of  and  careful  treatment  of  these  wounds,  and  furnish  veri- 
fication of  the  Hippocratic  aphorism  that  no  wound  of  the  head 
should  be  carelessly  treated. 


l.JG  CRANIUM. 

In  the  treatment  of  tlie  penetrating  wound  of  the  skull  a  car- 
dinal rule  should  be  that  tlie  surgeon  see  and  examine  the  in- 
strument which  caused  the  injury.  Thus  one  may  decide  whether 
a  fragment  has  been  left  in  the  wound  ;  also,  whether  the  entering 
object  was  clean  or  unclean.  Anotiier  rule  is  that,  where  the 
wound  in  the  scalp  is  a  slight  one  wliich  does  not  permit  a 
view  of  the  injured  skull,  and  there  be  a  suspicion  that  the  pen- 
etrating agent  has  been  broken,  then  the  track  of  the  wound 
should  be  laid  open,  and  the  cranial  wound  inspected:  and  should 
it  he  probable  that  a  fragment  remains  concealed  in  the  wounded 
bone  an  opening  should  at  once  be  made,  and  the  case  treated 
as  will  presently  be  explained.  Though  there  remain  a  broken 
fragment  of  the  instrument,  or  a  piece  of  the  inner  plate  be 
detached,  yet  for  a  few  days  probably,  no  symptom  will  indicate 
this;  for  intra-cranial  reaction  from  any  cause  is  only  slowly 
aroused;  and  when  once  awakened,  surgical  intervention  is  often 
too  late.  Hence  the  urgent  need  of  an  early  determination  of  the 
conditions.  If  it  be  evident,  or  even  probable,  that  a  fragment 
of  the  penetrating  object  has  l)een  left  in  the  wound,  then  if  it 
cannot  be  seized  and  extracted,  the  crown  of  a  small  trephine 
must  inclose  the  wound,  and  a  small  section  of  bone,  including 
the  object,  be  removed.  If  the  j^enetrating  object  be  not  wholly 
buried  in  the  bone,  then  with  a  proper  instrument  it  should  be 
seized  and  extracted.  Or  if  it  be  visible  and  yet  so  buried  that  it 
cannot  be  grasped,  then  the  bone  adjacent  may  be  removed  with  a 
chisel,  so  that  the  body  can  be  grasped;  for  the  removal  in  tliese 
ways  would  be  less  hazardous  to  the  patient  than  if  the  work  be 
done  with  the  trephine.  If,  however,  some  days  have  elapsed, 
and  symptoms  of  encephalic  irritation  are  appearing,  then  tlie 
tre])hine  should  be  used,  and,  if  pus  be  found,  the  part  should  be 
careful!}^  cleansed,  sprinkled  with  iodoform,  and  so  dressed  as 
to  })ermit  of  free  drainage.  The  patient's  head  should  rest  in 
such  a  position  that  any  material,  excreted  by  the  wound,  shall 
spontaneously  escape.  The  details  for  this  work  will  be  more 
fully  given  under  the  head  of  Trephination. 

In  case  the  penetrating  agent  has  entered  the  orbit  and  there 
be  signs  that  it  has  passed  through  the  orbital  foramen  or  sphe- 
noidal fissure,  or  has  pierced  the  thin,  bony  septum  which  at  cer- 
tain points  separates  the  eye  from  the  brain,  then  such  wound 
becomes  a  matter  of  the  gravest  consideration  to  the  surgeon. 
Should  there  be  a  visual  or  motor  disturbance  of  the  eye,  such 
lact  would  be  of  diagno.stic  assistance.     Should  the  causal  agent 


INCISED    WOUXDS    OF    THE    CRANIUM.  157 

have  left  a  fragment  behind,  then  its  extraction  must  be  at- 
tempted; and  even  if  the  eye  must  be  injured  in  the  work,  still 
it  must  be  done.  It  is  probable,  however,  that  where  the  object 
has  penetrated  the  supra-orbital  plate,  by  an  incision  made 
either  below  the  lid  or  through  its  base,  the  roof  of  the  orbit  can 
be  reached,  explored,  and  a  foreign  body  found  and  removed. 

Incised  Wounds  of  the  Cranium. — The  incised  wound  of  the 
skull  necessarily  includes  the  scalp.  Such  wounds  occur  in 
many  grades,  from  slight  to  ver\"  extensive.  The  wound  may 
merely  attack  the  surface  of  the  bone,  or  the  latter  may  be 
divided  through  its  entire  thickness.  The  bone  may  be  wounded 
perpendicularly  or  obliquely.  AVhere  the  bone  has  been  wholly 
divided,  the  adjacent  brain  may  be  wounded  also.  AVounds 
which  are  superficial,  both  the  perpendicular  and  the  oblique, 
are  seldom  dangerous  to  the  patient.  Far  more  grave  are  those 
which  penetrate  through  the  cranial  wall.  AVhen  the  wound 
passes  through  the  wall,  the  inner  plate  being  pierced,  a  frag- 
ment may  be  wholly  detached,  or  remain  adherent ;  in  each  case 
the  complication  is  a  dangerous  one. 

The  most  important  class  of  incised  cranial  wounds  is  that  in 
which  the  cutting  has  been  done  obliquely,  so  that  the  wound 
assumes  a  flap-like  form ;  and  the  bone  which  has  been  wounded 
may  be  completely  sliced  off,  or  it  may  be  only  incompletely 
separated  from  the  remaining  skull.  AVhen  not  entirely  sepa- 
rated, the  flap  has  a  hinge-like  pedicle,  so  that  the  wound  may 
be  opened  and  closed.  When  the  flap  has  been  wholly  severed,  its 
thickness  will  be  a  measure  of  the  injury  to  the  brain;  such  in- 
jury may  vary  from  a  simple  exposure  of  the  dura  mater  to  one 
in  which  a  section  of  the  brain  has  been  sliced  off.  An  incom- 
pletely severed  osseous  flap  may  become  entirely  separated 
through  fracture.  The  sharpness  or  bluntness  of  the  incising 
blade  will  have  an  influence  on  the  surface  of  the  wound;  frac- 
ture of  the  border  of  the  divided  bone  arises  from  a  blunt  instru- 
ment. 

The  treatment  of  the  incised  cranial  wound,  in  case  the  latter 
be  superficial,  is  simple:  it  may  be  limited  to  antiseptic  cleansing 
of  the  wound  in  the  scalp,  and  closure  by  suture,  or  tying  the 
hair  so  as  to  accurately  unite  the  edges  of  the  wound.  In  case  of 
a  perpendicular  wound  that  has  pierced  through  the  wall,  one 
must  carefully  examine  with  a  fine  probe  for  fragments  of  the 
fragile  inner  plate.  Such  fragment  is  so  often  present  that, 
though  it  cannot  be  found  in  this  exploratory  search,  yet  it  is 


158  CJtANlLM. 

better  to  omit  nothing  in  this  search;  and  though  it  would  add 
to  the  existing  wound,  still  it  would  be  better  to  convert  this  into 
a  less  perilous  one  by  using  a  small  trepliine  over  the  suspected 
point,  and  extracting  the  detached  or  partly  detaclied  fragment. 
If  this  exploration  seem  premature,  or  pushed  beyond  the  line  of 
caution,  it  may  be  answered  that  if  it  be  delayed  until  encephalic 
symptoms  plead  for  interference,  such  interference  will  almost 
certainly  prove  to  be  too  late.  But  if  the  exploration  be  done 
just  after  the  receipt  of  the  wound,  it  adds  but  little  to  the 
primary  wound;  but  if  done  later,  it  seldom  does  more  than  to 
arouse  to  action  and  intensify  the  latent  inflammation.  In  this 
work  conservative  judgment  and  vigilant  promptness  should 
have  full  participation;  promptness  in  action  should,  liowever, 
lead. 

In  case  of  cleft  or  iiap-wounds  of  the  cranium,  in  regard  to 
the  manner  of  treatment,  surgeons  have  not  been  in  accord:  where 
the  bone  flap  is  still  adherent  to  the  cranium,  the  usual  rule  is  to 
remove  splinters  or  fragments  of  bone,  hair  and  other  foreign 
matter  that  may  be  in  the  wound,  and  then  replace  the  bone,  and 
close  the  wound  in  the  scalp.  Sucli  wound  should  afterwards  be 
attentively  observed;  and  should  signs  of  encephalic  trouble 
arise,  the  wound  must  be  reopened  and  a  free  outlet  made  for 
subsequent  drainage.  But  in  those  cases  in  which  the  section  of 
bone  has  been  wholly  separated  from  the  rest  of  the  cranium,  and 
yet  the  scalp  wound  is  incomplete,  viz.,  the  severed  bone  is  covered 
by  integument  which  is  adherent  to  the  rest  of  the  scalp,  then  tlie 
course  of  treatment  has  been  a  matter  of  sharp  controversy  among 
military  surgeons.  The  plan  of  Pare  was  to  replace  such  a  flap, 
and  endeavor  to  obtain  reunion  of  the  bone.  Fallopius  and 
cotemporaries  of  Pare  opposed  this  plan;  they  advised  to  remove 
the  bone  and  close  the  wound  by  the  remaining  flap.  The  latter 
has  been  the  plan  pursued  by  most  surgeons,  and  the  results  have 
been  more  satisfactory  than  where  an  attempt  has  been  made  to 
save  the  bone;  since,  not  unfrecjuently,  such  bone  has  died,  so 
that  it  afterwards  became  necessary  to  reoijen  the  w^ound  and 
remove  the  necrosing  bone.  Guthrie,  a  famous  English  authority, 
counsels  to  examine  such  flap,  and  if  the  bone  is  extensively  sep- 
arated from  the  rest  of  the  flap,  then  it  should  be  removed;  but 
if  it  lias  unfractured  edges  and  is  well  adherent  to  the  tegumen- 
tary  flap,  then  the  bone  should  be  retained  and  an  attempt  be 
made  to  reunite  it;  by  this  plan,  wdiich  is  commonly  successful, 
the  integrity  of  the  cranium  will  be  restored.     Tlie  po.sition  of 


FK.ACTURE    OF    THE    CRANIUM.  159 

the  foot-stalk  of  such  flap  must  have  considerable  bearing  on  the 
life  or  death  of  the  bone  adherent  to  it;  when  the  pedicle  lies 
peripherally,  the  bone  will  be  less  apt  to  survive  the  violence 
than  when  the  pedicle  is  directed  towards  the  heart,  since  in  the 
latter  the  supply  of  blood  will  be  better.  The  smoothness  or 
roughness  of  the  incised  surfaces  will  favor  or  oppose  reunion. 
Unless  the  position  of  the  pedicle  and  the  nature  of  the  cut 
surfaces  be  very  favorable  for  reunion,  it  woujd  be  safer  to  sacri- 
fice the  detached  section  of  bone;  the  bone  then  should  be 
cautiously  dissected  from  the  tegumentary  flap,  care  being  taken 
to  preserve  the  periosteum.  If  the  work  be  thus  done,  one  might 
hope  that  some  bone  would  be  formed  beneath  the  retained  peri- 
osteum, similarly  to  what  occurs  in  the  rhinoplastic  operation,  in 
which  the  periosteum  is  preserved  with  the  flap  taken  from  the 
forehead,  as  was  practiced  by  Langenbeck. 

Fracture  of  the  Cranium,. — This  is  one  of  the  oldest  chapters  in 
the  history  of  surgery,  and  in  many  respects  was  as  well  described 
four  hundred  years  before  our  era  as  it  can  be  done  to-day;  for 
in  Hippocrates  one  finds  that  which  the  modern  writer,  in  the 
main,  repeats.  The  cranium,  in  which  nature  has  stored  the  most 
precious  portion  of  the  human  organism,  is  frequently  broken  by 
accidental  violence,  or  by  that  which  is  intentionally  inflicted  by 
man  on  himself  or  on  his  fellow. 

The  skull  may  be  broken  by  direct  or  indirect  violence;  the 
former  is  by  far  the  more  frequent.  Examples  of  fractures 
through  direct  violence  are  those  in  which  a  club,  missile,  or 
some  falling  body  strikes  the  head  and  breaks  the  cranial  wall. 
Again,  the  cranium  may  be  fractured  by  a  fall  from  a  height, 
through  railway  accident,  or  the  overturning  of  a  carriage. 
Fracture  from  indirect  cause  is  where  the  violence  is  transmitted 
from  some  more  remote  point  to  which  the  force  was  primarily 
communicated;  such  force  may  be  first  communicated  to  the 
crown  of  the  head,  the  face,  especially  the  chin,  or  to  the  feet. 

There  are  varying  grades  of  fracture,  viz.,  fissure,  stellate,  or 
fracture  in  star  form,  fracture  with  depression,  and  communicated 
fracture  with  or  without  depression.  The  cranium  may  be  broken 
in  more  than  one  place  at  the  same  time.  The  wall  may  be 
incompletely  fractured,  in  which  the  outer  plate  only  is  broken, 
or  the  inner  plate  may  be  cracked  wdiile  the  outer  one  remains 
intact.  Also,  there  may  be  inequality  between  the  fragments  of 
the  inner  and  the  outer  plate;  as  a  rule,  the  outer  fragment  is  the 
larger  one;  yet  the  outer  one  may  be  small  and  the  inner  one 


160  CRANIUM, 

much  greater  in  magnitude.  The  fracture  of  the  skull  may  be 
the  only  injury,  since  it  may  exist  while  the  scalp,  dura  mater 
and  brain  are  injured.  Or  the  scalp  may  be  openly  wounded 
over  the  cranial  fracture;  or  the  skull  may  be  broken  along  with 
lesion  of  the  dura  mater  and  brain,  while  tlie  overlying  scalp  is 
unopened.  Each  of  the  fractures  enumerated  are  dangerous,  and 
not  unfrequently  end  the  life  of  the  patient,  though  tlie  danger 
is  far  from  being  directly  proportionate  to  the  extent  of  tlie  frac- 
ture; for  a  slight  fissure  has  destroyed  life,  while  a  great  fracture 
in  which  a  large  breach  has  been  made  in  the  wall  through  loss 
of  bone,  has  not  killed  the  subject,  as  might  have  been  appre- 
hended. Hence,  accurate  certainty  in  prognosis  cannot  be 
attained  in  these  injuries;  though  extent  and  range  of  experience 
may  aid  the  surgeon,  he  can  never  infallibly  foretell  the  ultimate 
events  of  a  fractured  skull,  and  even  though  life  be  retained,  yet 
often  the  nijury  leaves  an  indelible  defect  in  the  mentality  of  the 
victim. 

As  has  been  said  before,  there  is  a  small  class  of  cranial  frac- 
tures in  which  the  causal  violence  strikes  the  body  at  some  point 
other  than  tliat  which  is  the  site  of  fracture;  thus  a  blow  on  the 
summit  of  the  head,  on  the  chin,  or  a  fall  on  the  feet,  knees,  or 
ischia.may  cause  fracture  at  tlie  base  of  the  skull.  This  fracture 
has  been  the  subject  of  much  controversy.  It  was  once  tauglit 
that  when  the  point  of  first  impact  was  the  head,  the  violence 
traveled  from  the  point  of  primary  contact  to  the"  bone  which  was 
broken,  without  lesion  of  the  intermediate  structures.  More 
accurate  observation  has  rendered  this  uncertain,  and,  especially, 
experiments  made  on  the  cadaver  have  rendered  it  doubtful. 
Aran,  in  1S44,  published  the  results  he  obtained  from  a  series  of 
experiments;  he  concludes  that  "a  fracture  never  occurs  at  the 
base  of  the  skull  without  there  being  likewise  a  fracture  at  the 
point  which  was  first  struck,  A  fracture  of  the  vault  of  the 
cranium  may  travel  by  radiation  to  the  base;  even  the  sutures  do 
not  oppose  the  passage  of  the  radiating  fracture;  tlie  line  of  frac- 
ture takes  the  shortest  course;  that  is,  it  follows  tlie  curve  of  the 
shortest  radius."  This,  though  nearly  correct,  is  not  wholly  so, 
since  both  by  experiments  made  on  the  dead  body,  as  well  as 
through  necropsy  of  those  who  had  died  from  cranial  fracture, 
such  isolated  injury  has  been  found  at  the  base  of  the  skull. 
Hence  the  old  surgeons  were  right  in  their  doctrine  of  independ- 
ent fracture  at  the  cranial  base  from  transmitted  or  indirect  force, 
though  it  is  much  more  rare  than  they  thought;  we  are,  therefore, 


FRACTURE  OF  THE  CRANIUM.  161 

not  justified  in  erasing  from  the  page  of  surgery,  as  some  would 
do,  the  word  contre-coup,  the  French  term  by  wliich  the  injury  is 
commonly  designated  by  tl:ie  English  writer;  or  counter-fracture, 
as  the  name  becomes  when  anglicized. 

The  symptoms  of  fracture  are  of  two  kinds,  physical  and 
rational.  The  physical  signs  are  those  which  reveal  themselves 
to  the  sight  and  touch  of  the  surgeon.  When  the  scalp  is  entirely 
opened,  and  the  skull  can  be  felt  and  seen,  then  the  character 
and  extent  of  the  injury  can  readily  be  learned,  especially  wdiere 
the  breach  is  an  extensive  one;  by  palpation  and  inspection,  it 
can  then  be  learned  whether  there  be  depression  of  bone,  and 
whether  there  are  fragments  in  large  or  comminuted  form.  The 
most  valuable  knowledge  obtained  by  this  inspection  is  whether 
there  is  anything  escaping  through  the  opened  cranial  wall.  For 
example,  if  cerebral  matter  be  seen  exuding,  this  indicates  that 
the  inclosing  membranes  and  the  brain  have  been  penetrated  ; 
or  if  a  serous  fluid  only  is  escaping,  tliis  denotes,  probably,  an 
isolated  injury  of  the  dura  mater,  and  that  the  fluid  escaping  is 
the  cerebro-spinal  liquid.  Thus,  when  the  bone  is  exposed,  the 
extent  and  gravity  of  the  injury  doiie  can  be  accurately  estimated. 
The  case,  however,  in  which  sight  and  touch  may  err,  is  where 
the  fracture  is  a  simple  fissure.  A  suture  has  been  mistaken  for 
such  fissure,  and  this  is  more  apt  to  occur  in  regions  which  are 
the  occasional  site  of  abnormal  suture.  For  example,  in  a  small 
percentage  of  cases,  the  sagittal  suture  is  continued  through  the 
frontal  bone;  and,  as  a  rare  anomaly,  there  may  be  a  transverse 
suture  dividing  the  occipital  bone  into  two  portions.  Saucerotte 
mentions  one  instance  of  the  latter  in  a  clergyman,  who,  after  a 
fall  on  his  occiput,  was  on  the  eve  of  being  trephined,  yet  one  of 
the  consultants  claimed  that  the  supposed  fracture  was  a  suture: 
the  patient  was  rescued  from  the  trephine,  and  in  his  gratitude 
willed  his  skull  to  the  surgeon  who  prevented  the  operation.  As 
errors  have  been  made  on  this  side,  so  it  can  be  conceived  that 
they  might  be  made  in  mistaking  a  fissure  for  a  suture.  For 
instance,  in  the  old  subject's  skull,  a  suture  that  has  been  closed 
might  be  reopened  in  fissured  form.  In  former  times,  when  the 
trephine  was  the  inseparable  follower  of  the  fissured  fracture,  the 
diagnostic  determination  of  the  latter  was  pushed  to  the  verge  of 
pedantic  refinement.  Some  staining  material,  as  ink,  was  poured 
on  the  suspected  point;  a  rasp-like  instrument  was  next  used, 
and  the  surface  removed;  if  there  was  a  fissure  this  was  discov- 
ered by  traces  of  the  ink  which  had  penetrated.     Since  the  use 


1G-!  CKANIUM. 

of  the  trephine  has  ceased  to  be  a  fashion,  and  this  instrument 
has  been  restricted  to  exceptional  employment,  such  adventurous 
method  of  diagnostic  exploration,  as  that  referred  to,  has  ceased. 

Formerly,  where  a  cranial  fracture  was  suspected,  and  tlie 
scalp  was  unopened,  the  practice  obtained  of  opening  the  soft 
parts,  so  that  the  bone  suspected  of  injury,  could  be  seen.  This 
practice  is  now  wisely  limited  to  those  cases  in  which  the 
patient's  symptoms  indicate  internal  injury  of  the  head,  whicli 
demands  surgical  interference;  in  the  absence  of  such  indication, 
the  conversion  of  a  subcutaneous  fracture  into  an  open  one  would 
be  a  wanton  meddlesomeness  deserving  of  strong  reprehension. 

A  partial  breach  of  the  scalp,  caused  by  some  direct  violence, 
has  been  mistaken  for  a  fracture  with  depression;  and  only 
through  some  tactile  experience  can  such  error  be  avoided.  In 
such  injury  of  the  scalp,  the  finger  sinks  into  what  seems  mani- 
festly to  be  a  sunken  condition  of  the  bone.  There  will,  however 
be  found  a  quick  transition  from  the  apparent  depression  in  the 
bone,  to  the  normal  structure  of  the  scalp.  The  finger  rests  in  a 
hollow  arising  from  a  partial  breach  of  the  scalp,  and  the  broken 
tissues,  somewhat  abruptly  bounding  and  walling  the  sunken 
point,  are  indurated.  In  such  pseudo-depression  tlie  bounding 
wall  is  more  rounded  and  less  resistant  than  is  the  case  in  cranial 
fracture  with  depression  of  the  bone. 

The  old  surgeons  had  a  number  of  odd  signs  w^hich  they 
valued  as  indications  of  fracture;  for  examjDle,  the  pain  that  was 
awakened  at  the  site  of  fracture  when  the  patient  crushed  some 
hard  object  between  the  molar  teeth  ;  or  when  a  handkerchief 
was  seized  between  the  teeth  and  this  was  jerked,  pain  was  felt  at 
the  place  of  fracture.  Or  if  the  patient  was  unconscious,  and 
moved  his  hand  to  some  part  of  the  head,  this  was  thought  to 
signify  fracture  at  the  point  touched  by  the  patient.  These  signs 
have  lost  their  former  value;  in  fact,  but  little  importance  is  now 
attached  to  them. 

When  some  time  has  elapsed  since  the  injury  was  received, 
continued  swelling  or  cedema  over  the  site  of  it  has  been 
thought  significant  of  subjacent  fracture.  Or  if  the  bone  is  open 
to  view,  its  condition,  even  if  unfractured,  is  suggestive ;  for  if 
dry,  gray  or  yellow,  encephalic  lesion  may  be  inferred  ;  subjacent 
pus  may  be  suspected. 

When  the  fracture  is  seated  in  the  lower  part  or  base  of  the 
skull,  though  some  of  the  conditions  above  described  are  present 
yet  it  has  peculiarities  and  cliaracteristics  which  require  some 


FRACTURE  OF  THE  CRANIUM.  163 

further  description.  Such  fracture  may  be  from  direct  or  indi- 
rect violence.  In  that  from  direct  force  the  fracture  may  be  with, 
or  without,  an  opening  through  the  external  soft  parts.  Tlie 
causal  agency  is  oftenest  some  missile  or  projectile.  As  the  base 
of  the  skull  is  nearly  inaccessible  to  sight  and  touch,  exploration 
of  injury  there  is  much  more  difficult  than  when  it  is  in  the 
cranial  vault.  And  even  when  in  the  borders  of  the  base,  the 
thickness  of  the  overlying  soft  parts  interferes  with  accurate  pal- 
pation. Tlie  sterno-cleido  mastoid,  splenius  and  complexus 
muscles  both  protect  and  pretty  effectually  hide  the  bones 
beneath  them. 

From  indirect  violence  or  transmitted  force,  as  before  men- 
tioned, the  irregular  structure  composing  the  base  of  the  skull 
may  be  broken.  Such  fracture  would  be  indicated  especially  bv 
functional  disturbance  of  adjacent  parts.  Thus  nerves  and  blood 
vessels  may  be  compressed  or  torn,  and,  in  case  of  the  nerves,  the 
result  would  be  the  abolition  or  perversion  of  their  normal  office; 
thus  might  arise  disturbance  of  motion  and  common  and  special 
sensation.  There  is  some  interruption  of  the  media  or  routes  of 
intercommunication  between  the  head  and  the  trunk  and  limbs. 

Fracture  occurring  at  some  point  of  the  base  of  the  cranium 
may  be  indicated  by  ecchymosis,  htemorrhage,  efl'usion  of  serous 
fluid,  or  crushed  cerebral  matter. 

If  the  fracture  be  located  behind,  there  may  be  ecchymosis  of 
blood,  visible  through  the  skin,  in  the  inferior  occipital  region, 
and  especially  behind  the  ear.  Or  if  the  fracture  be  in  the 
anterior  structures  of  the  base,  then  the  ecchj^mosis  may  appear 
in  the  eye,  or  in  the  pharynx.  In  all  these  cases,  the  ecchymosis 
does  not  instantly  appear;  it  only  does  so  after  the  lapse  of  a 
brief  time;  the  blood,  having  penetrated  the  tissue  from  within, 
gradually  travels  thence  and  finally  appears  at  the  surface.  Such 
ecchymosis  should  not  unreservedly  be  depended  on  as  furnish- 
ing certain  evidence  of  fracture.  The  author  has  seen  cases  in 
which  ecchymosis  was  present,  where  he  was  convinced  that  no 
fracture  existed,  but  that  the  effused  blood  was  from  superficial 
vascular  lesion  due  to  violent  concussion.  This  is  frequently  the 
case  where  the  effusion  is  sub-conjunctival. 

Hcemorrhage  from  the  ear,  nose  and  pharynx,  denotes  lesion 
of  blood  vessels  caused  by  fracture  of  bone  adjacent  to  the  site  of 
the  escape  of  blood.  From  the  ear,  it  would  imply  that  some  por- 
tion of  the  temporal  bone  had  been  broken,  but  if  this  symptom 
be  too  implicitly  followed,  it  mav  mislead;  for  bleeding  from  the 


1G4  CRANIUM. 

ear  has  been  seen,  several  times,  by  the  author  where  tlie  injury 
was  not  deeper  than  the  external  auditory  canal.  Bleeding  from 
the  ear  may  be  caused  by  rupture  of  the  typaiium,  by  lesion  of 
the  auditory  canal,  by  fracture  of  the  adjacent  mastoid  process, 
and  it  can  arise  from  other  injuries  of  the  head  in  which  the  skull 
is  not  broken.  Where  there  is  fracture  of  the  base,  there  may  be 
only  tire  appearance  of  specks  of  blood  in  the  external  outlet 
and  lobule  of  the  ear.  In  other  cases,  the  blood  slowly  trickles 
from  the  auditory  meatus,  or  it  may  flow  in  a  constant  stream; 
and  in  tlio  latter  cases  an  artery,  or  sinus,  has  been  opened 
coincidently  with  a  fracture  of  the  skull. 

The  blood  may  escape  from  the  nose  and  moutli  tlirough 
fracture  of  the  base;  and  there  may  likewise  be  simultaneous 
issuing  of  blood  from  the  nose,  mouth  and  ear,  due  to  frncture  of 
the  base;  still  it  must  be  remembered  that  such  ha3morrliage  may 
arise  from  otlier  causes  than  cranial  fracture. 

The  escape  of  serous  liquid  from  the  ear  and  nose  indicates 
fracture;  that  from  the  ear  denotes  fracture  of  tlie  petrous  portion 
of  the  temporal  bone.  It  may  have  been  preceded  or  accompa- 
nied by  haemorrhage;  it  is  of  more  diagnostic  certainty  when 
unaccompanied  by  bleeding.  The  fluid,  for  a  time,  was  thought 
to  be  from  tlie  internal  ear  that  had  been  opened;  it  is  now  known 
to  be  the  cerebro-spinal  fluid,  since  it  has  been  shown  to  be 
chemically  identical  with  the  latter.  Large  quantities  of  this 
fluid  have  sometimes  been  lost.  The  same  fluid  may  escape  from 
the  nose;  then  the  sphenoid  bone  is  the  site  of  fracture.  The 
flow  of  this  serous  fluid  may  continue  for  hours,  or  even  days. 
When  it  appears  some  hours  after  the  injury,  and  there  has 
been  antecedent  hemorrhage,  and  the  escape  of  the  liquid  is 
variable  in  amount,  then  it  is  more  equivocal,  and  must  be 
reckoned  as  a  certain  sign  of  fracture. 

Observations  made  in  regard  to  the  temperature  of  the  subjects 
of  cranial  fracture  have  revealed  the  following  facts:  During  the 
period  of  shock  and  depression  which  immediately  follows  severe 
cranial  injury,  the  heat  of  the  body  sinks  below  the  normal  rate, 
viz.,  to  97°  Fahr.  or  even  lower;  then  there  is  a  moderate  rise, 
which,  not  unfrequently,is  followed  by  a  depression  of  temperature, 
which  continues  for  some  days.  The  increase  of  temperature 
depends  on  the  lesion  of  the  encephalic  structures,  rather  than  on 
that  of  the  cranial  wall,  and  rise  of  temperature,  gradual  or 
abrupt,  denotes  morbid  action  of  the  parts  outside  of  or  within  the 
skull;  abscess  or  erysipelas  in  the  scalp  would  thus  be  indicated  ; 


FEACTUEE    OF    THE    CRANIUM.  165 

and  so  meningitis,  encephalitis  and  intracranial  abscess  might 
reveal  themselves  by  increased  heat.  Such  augmented  tempera- 
ture might  arise  from  both  intra-cranial  and  extra-cranial  morbid 
action,  and,  hence,  in  erysipelas  or  abscess  of  the  scalp,  one  would 
not  be  justified  in  referring  the  rise  of  temperature  wholly  to 
these  extra-cranial  conditions.  In  his  study  of  the  fractures  of 
the  base  of  the  skull,  Battle  has  met  with  a  few  cases  in  which  a 
few  hours  after  the  receipt  of  the  injury,  the  temperature  rose  to 
the  enormous  extent  of  ten  degrees  above  the  normal  rate;  he 
says  that  such  great  increase  of  heat  portends  a  fatal  termination, 
and  is  due  to  severe  contusion  of  the  brain. 

The  functional  disturbance  in  cases  of  cranial  fracture  depends 
on  the  amount  of  injury  done  to  the  brain.  The  violence  seems 
often  to  expend  itself  in  the  fracture,  and,  in  such  favorable 
condition,  the  encephalon  being  intact,  the  fracture  becomes  a 
lesion  of  no  great  importance.  In  such  a  case,  the  fracture  may 
be  looked  upon  as  a  conservative  evejit,  in  which  the  injury  ends. 
If  the  violence  had  not  thus  been  expended  or  used,  it  would  have 
passed  inward  into  the  cranial  cavity,  and  done  its  work  in  the 
graver  work  of  cerebral  concussion.  And  thus,  not  rarely,  is  seen 
the  paradox  that  a  patient,  who  has  fracture  of  the  skull,  is  much 
less  injured  than  one  whose  cranium  was  not  broken;  the  former 
may  rise  and  walk,  and  declare  himself  but  slightly  injured, 
while  the  latter,  having  concussion  of  the  brain,  lies  unconscious, 
and  is  most  seriously  injured. 

The  region  of  the  skull  fractured  has  an  important  bearing 
on  the  gravity  and  danger  of  the  injury.  Fracture  in  the  ante- 
rior half  of  the  cranial  vault  is  less  dangerous  than  in  the  posterior 
half.  From  the  author's  experience,  a  fracture  in  the  region  of 
the  forehead  is  better  tolerated  than  elsewhere;  cases  have  been 
seen  in  which  the  frontal  bone  had  been  broken  most  extensively, 
and,  though  fragments  were  lost  and  cerebral  matter  escaped, 
still  the  patients  recovered.  A  fracture  in  the  occipital  region  is 
more  dangerous  than  when  seated  anteriorly;  yet,  in  both  cases, 
the  character  and  conditions  of  the  fracture  determine  the 
amount  of  danger  which  it  brings  to  the  patient.  An  open 
fracture  in  which  the  integument  has  been  torn,  the  bone  broken 
into  two  or  more  pieces,  and  these  pieces  have  been  removed,  is  oc- 
casionally folio  wed  by  recovery,in  any  portion  of  the  cranial  vault; 
while  a  fracture  on  a  much  smaller  scale,  in  which  no  bone  has 
been  lost,  more  often  ends  unfavorably.  For  in  the  former  case,in 
which  the  fracture  is  open,  the  surgeon  is  able  to  dress  the  wound 


IGG  CUANIUM. 

more  conformably  to  the  con<litions  which  favor  liealing;  osseous 
fragment.^  can  be  removed,  bleeding  arrested,  and  the  margins  of 
the  broken  bone  can  be  restored  to  normal  site ;  work  that  cannot 
easily  be  done  in  a  smaller  fracture. 

A  fracture  in  any  part  of  the  base  of  the  skull  is  more  hazar- 
dous to  life  than  one  in  the  cranial  vault;  for  the  reason  that 
more  important  parts  of  the  ence})halon  are  thereby  imjjeri led; 
danger  increases  as  the  medulla  oblongata  is  approached.  In  an 
exhaustive  study  of  fractures  of  the  base  of  the  skull,  published 
in  1890  by  W.  H.  Battle,  of  London,  this  writer  has  collected 
fifty -four  cases  which  ended  fatally;  in  nearly  two-thirds  of  the 
cases  the  cause  of  death,  as  revealed  by  necropsy,  was  from 
cerebral  contusion  with  laceration  and  haemorrhage.  Death 
occurred  in  from  one  hour  to  fourteen  days;  the  most  died  within 
three  days  after  the  injury. 

Though  the  danger  from  these  injuries  may  be  estinjated  with 
a  fair  degree  of  probability,  yet  the  keenest  prognostic  acumen 
often  errs,  since  the  seemingly  trivial  fracture  may  destroy  life, 
while  a  breach  a  hundred-fold  greater  has  often  defeated  fatal 
predictions  by  ending  in  recovery;  the  latter  error  escapes  crit- 
icism; since  all  is  well  that  ends  well. 

A  fracture  of  the  cranial  bones  is  less  perfectly  repaired  than 
elsewhere;  though  the  broken  bone  be  but  thin  in  extent,  and  is 
invested  externally  and  internally  by  a  periosteum,  still  there  is 
a  very  limited  amount  of  callus  produced;  so  that  union  is  accom- 
plished chiefly  through  the  medium  of  fibrous  tissue.  The  oi)po- 
site  fractured  borders  are  connected,  similar  to  a  cranial  suture, 
by  a  thin  la}- er  of  non-vascular  fibrous  tissue. 

Treatment. — Since  fracture  of  the  skull  presents  itself  in  vary- 
ing degrees  of  severity,  so  the  treatment  must  vary  in  character; 
and  as  the  ence})halic  complication  is  far  more  important  than 
the  injury  of  the  cranial  wall,  so  the  former  must  ever  be  kept 
prominently  in  view;  in  fact,  it  must  claim  the  principal  share 
of  attention.  At  present,  only  the  fracture  will  be  considered,  as 
a  special  section  will  be  devoted  to  injuries  of  the  brain. 

The  treatment  of  cranial  fracture  has  been  the  subject  of 
sharp  controvers}'^;  methods  long  held  in  reverence  have  been 
rejdaced  by  those  quite  opposite  to  former  ones.  For  centuries 
trephination,  as  a  shadow,  was  the  inseparable  sequent  of  a  frac- 
ture of  the  skull;  even  in  case  of  the  minutest  fissure,  this  instru- 
ment was  used,  and,  in  the  exploratory  work  done  with  it,  the 
cranial  injury  was  increased  many  times.     Such   instrumental 


FRACTURE    OF    THE    CRANIUM,  167 

interference  is  now  seldom  resorted  to;  and  by  its  present  con- 
servatism, surgery  has  removed  a  trammel  with  which  nature 
formerly  had  to  contend  in  the  work  of  restoration. 

In  a  simply  fissured  fracture,  or  one  in  which  there  is  slight 
depression  without  symptoms  of  cerebral  disturbance,  the  treat- 
ment is  exceedingly  simple;  the  patient,  or  rather  his  head,  should 
be  placed  at  rest;  the  ear  and  eye  should  cease  their  work;  in 
fact,  the  door  of  all  the  senses  should  be  closed  against  external 
impressions.  These  precautions,  even  though  the  brain  has  been 
spared  any  injury,  will  not  harm;  and  if  the  organ  has  received 
a  latent  lesion,  such  precautions  may  prevent  further  develop- 
ment. If  the  alimentary  canal  was  laden  with  materials  at  the 
time  of  the  accident,  these  should  be  removed  by  a  proper  cathar- 
tic. Fortunately  much  of  this  material  is  often  gotten  rid  of  by 
spontaneous  vomiting.  This  vomiting,  probably  called  into 
action  through  the  pneumogastric  nerve  and  the  sympathetic 
nervous  chain  which  connect  the  head  and  stomach,  usually 
ceases  as  soon  as  the  stomach  is  emptied. 

Along  with  these  matters  of  general  management,  the  injury 
of  the  head  demands  some  local  treatment.  If  there  be  a  breach 
in  the  scalp,  this  must  be  dressed  by  one  of  the  methods  before 
described,  best  adapted  to  it.  And  if  there  be  no  open  breach, 
the  management  of  the  wound  will  be  limited  to  a  topical  appli- 
cation; and  for  this,  cold  in  some  form  has  general  sanction.  This 
may  be  applied  in  the  form  of  a  compress  saturated  with  cold 
water,  or  broken  ice  or  snow,  in  an  India  rubber  bag,  may  be 
placed  over  the  injured  part.  As  ice  and  snow  may  freeze,  and 
have  done  so  when  indiscreetly  used,  there  should  be  interposed 
between  the  containing  sack  and  head  a  piece  of  cloth,  woolen  or 
cotton.  If  a  compress  merely  wet  with  water  be  used,  such  com- 
press is  best  made  from  some  porous  or  wide-meshed  material; 
mosquito  netting,  of  which  several  thicknesses  are  folded  together, 
serves  the  purpose  well.  Such  a  compress  wrung  out  of  cold 
water  will  retain  the  cold  and  moisture  for  some  time;  and  there 
will  be  little  inconvenience  from  the  water  escaping,  as  occurs 
when  the  compress  is  made  of  closer  texture.  Cold  with  moisture 
is  more  agreeable  than  dry  cold. 

In  regard  to  the  topical  use  of  cold  in  the  treatment  of 
wounded  parts  of  the  head,  when  the  matter  is  studied,  there  is 
some  difficulty  in  understanding  how  the  cold  can  act  bene- 
ficially. For  the  immediate  effect  will  be  to  contract  the  vessels 
which  are  cooled,  and  thus  lessen  the  quantity  of  blood  which 


108  CRANIUM. 

enters  the  arteries,  and  cold  will  also  empty  the  veins;  the  result  of 
this  must  necessarily  be  to  increase  the  amount  of  blood  con- 
tained in  the  structures  around  and  beneath.  Only  where  the 
scalp  is  thin  can  the  action  of  cold  reach  into  the  underlying 
bone;  but  when  the  covering  structures  arc  thick,  then  the  blood 
would  merely  be  collected  in  greater  quantity  in  the  underlying- 
cranial  wall.  Hence  it  is  probable  that  in  most  cases,  the  local 
use  of  cold  to  the  head  is  hyperiennc,  rather  than  amemic,  in  its 
action  on  the  injured  bone.  And,  further,  in  those  regions  which 
are  the  site  of  the  emissaries  of  Santorini,  or  canals  of  intercom- 
munication between  the  extra-cranial  and  intra-cranial  structures, 
the  effect  of  cold  is  to  cause  the  blood  to  flow  from  the  cooled 
scalp  into  the  skull,  and  there  cause  a  local  hyperaem.ia;  in  fact, 
the  cold  in  such  case  does  quite  the  opposite  of  what  it  is  intended 
to  do.  Emissaries  of  Santorini  exist  in  the  lower  margin  of  the 
forehead  and  in  the  parietal  bones;  hence  cold  applied  over  these 
regions  causes  an  atflux  of  blood  into  the  skull.  And  though  the 
author  has,  in  accordance  with  common  usage  and  authorit}', 
advised  the  local  use  of  cold  in  these  injuries  of  the  head,  yet  it  is 
equivocal  whether  local  cold  here,  as  well  as  elsewhere,  is  actually 
beneficial.  The  subjective  experience  of  the  patient  often  influ- 
ences or  directs  the  treatment;  the  wounded  part  being  benumbed 
by  cold  loses  its  sensibility,  and  this  fiict  probably  first  led  to  the 
use  of  cold.  A  {)ossible  benefit  from  cold  is  conceivable  where  the 
blood  in  the  seal]),  being  cooled,  traverses  the  wall  and  lowers 
the  temperature  within  the  skull;  but  here,  as  not  unfrequently 
occurs  elsewhere,  the  medical  writer  who  is  seeking  to  give  truths, 
pauses  in  embarrassment  and  must  ask  his  reader  to  await  until 
Theory  and  Experience,  becoming  more  intimately  acquainted, 
shall  unite  in  a  common  task  of  reconciling  and  adjusting  con- 
tradictory and  incoherent  facts. 

In  case  both  scalp  and  cranium  have  been  opened  and  there 
be  no  depression,  then,  after  removing  fragments,  the  margins  of 
the  broken  bone  should  l>e  carefully  attended  to,  viz.,  if  there  be 
depression,  the  edges  should  be  lifted  into  proper  position. 
Besides  being  restored  to  position,  broken  edges  should  be  trimmed 
w'ith  extreme  care  and  rendered  perfectly  smooth.  If  this  pre- 
caution be  neglected,  tlie  adjacent  encephalon,  moving  under  the 
influx  and  efflux  of  blood,  will  be  brought  in  contact  with,  and 
irritated  by,  any  sharp  j)oint  impinging  against  it.  And,  though 
this  irritation  be  slight  and  produce  but  little  present  trouble, 
yet,  after  the  part  has  healed,  the  overhanging  osseous  promonto- 


FRACTURE    OF    THE    CRAXIUM.  169 

ries  may  increase  in  thickness  and  become  an  enduring  source  of 
irritation;  thus  epilepsy  has  been  caused,  and  continued  until  the 
causal  agent  was  removed.  In  one  instance  seen  by  the  author, 
from  the  osteophytic  irregularities  of  a  fracture  of  the  vault,  sup- 
puration arose,  with  opening  of  the  old  wound,  and  prolapsus  of 
the  brain,  from  which  death  ensued  in  a  few  weeks. 

Healing,  as  before  said,  even  in  fissural  fracture,  is  through 
the  medium  of  fibrous  tissue;  and  where,  from  the  loss  of  bone, 
the  broken  edges  are  not  in  contact,  then  the  interljdng  breach  is 
closed  by  fibrous  material.  This  tissue  is  analogous  to  that  com- 
posing cicatricial  structure  closing  a  breach  on  the  surface  of  the 
body.  And  this  is  true  in  all  varieties  of  open  wounds  of  the 
cranium,  whether  merely  bone  lias  been  removed,  or,  in  addi- 
tion to  this,  whether  the  meninges  have  been  opened  and  partially 
destroyed:  and,  likewise,  where  there  has  been  loss  of  bone,  mem- 
brane and  cerebral  substance;  in  each  of  these  conditions  of 
wound,  the  healing  is  through  the  medium  of  granulations,  which 
finally  become  converted  into  normal  cicatricial  structure.  And 
this  reparative  material  does  not  completely  fill  the  breach;  there 
is  afterwards  left  a  depression,  arising  from  the  contraction  and 
sinking  of  the  new-formed  material;  and  a  consequence  of  this  is 
that  the  adjacent  brain  is  disturbed  in  situation  and  form.  As 
a  result,  there  sometimes  remains  functional  impairment;  and 
this  is  more  especially  so  in  the  young  subject,  in  whom  the  parts 
have  not  attained  the  dimensions  of  adult  life.  Such  maimed 
heads  are  often  the  victims  of  epileptic  or  other  encei^halic  disease. 

The  treatment  of  cranial  fracture  in  which  the  bone  is 
depressed  has  been  the  subject  of  shifting  change.  Formerh'  the 
trephine  always  found  work  to  do  in  such  injury,  and  a  surgeon, 
who  would  have  neglected  to  perforate  tlie  sunken  wall  in  such 
case,  would  have  been  deemed  guilty.of  great  carelessness  towards 
his  patient.  The  opposition  to  trephination,  which  is  one  of  the 
conspicuous  events  in  the  history  of  modern  surgery,  has  quite 
reversed  the  management  of  such  injury,  so  much  so  that  he,  who 
would  invariably  trephine  in  cases  of  depressed  cranial  fracture, 
would  be  pronounced  guilty  of  wanton  temerity.  In  the  annals 
of  medicine  similar  examples  are  met  in  which  the  pendulum  of 
opinion,  swinging  to  and  fro  between  adverse  doctrines,  through 
the  zeal  of  the  contestants  has  been  made  to  move  too  far  in  each 
direction;  but  as  the  pendulum  committed  to  the  constant  force 
of  gravitation  soon  resumes  its  normal  arc,  so  the  controlling 
power  of  truth  is  ever  adjusting  medical  opinion  to  its  own  stand- 
12 


17v)  (  r.ANir.M. 

art.].  The  author  is  of  the  opinion  that  the  sweeping  renuncia- 
tion of  the  trephine  is  an  error  in  practice;  still  lie  would  not 
adopt  the  medium  way,  as  the  compromiser  is  wont,  between  the 
old  practices,  since  the  middle  line,  instead  of  being  the  safest,  is 
too  narrow  for  occupancy  and  action.  Ex})erionce  permits  and 
indicates  the  use  of  the  trephine  in  cases  of  fracture  in  which 
there  is  extensive  depression  of  the  cranial  wall.  For  such  de- 
pression, if  unrelieved,  must  hamj)er  the  brain  in  its  functions. 
Of  these  multifarious  functions,  that  of  motor  innervation  is  one 
of  which  the  site  has  been  definitely  located  in  the  surface  of  the 
brain;  the  others  have  doubtless  their  special  sites,  and  await  for 
the  exploring  hand  of  vivisection  to  discover  and  indicate  them. 
Tiie  encroachment  of  a  depressed  cranial  wall  must  interfere  with 
any  such  subjacent  center,  impairing  its  nutrition  and,  partly  or 
completely,  annulling  its  function.  In  the  plastic  period  of  youth, 
the  changes  in  the  wall  occurring  through  growth,  may  finally 
compensate  or  efface  the  ill  form;  but  where  the  cranium  has 
attained  its  complete  form,  such  depression  must  be  more  detri- 
mental in  its  action,  since,  if  unrelieved,  the  deformity  will  be 
permanent. 

Guided  by  these  principles,  the  author  would  use  the  trephine 
and  uplift  the  bone  in  every  case  in  which  there  is  an  extensive 
depression  of  the  cranial  wall.  For  this  purpose,  with  precau- 
tionary asepsis,  a  small  opening  shall  be  made  in  the  center  of 
the  depressed  bone,  and  the  latter  carefully  uplifted  with  an  ele- 
vator. This,  in  the  young  subject,  can  easily  be  done,  but  in  the 
old,  the  work  of  elevating  is  more  difficult;  and,  in  the  latter,  there 
may  have  occurred  an  isolated  fracture  of  the  inner  plate,  so  that 
a  fragment  must  be  removed;  and  in  such  case  the  patient  will 
afterwards  bo  indebted  to  the  trephine  for  saving  his  life.  In 
the  work  of  elevating,  care  must  be  u.sed  not  to  injure  the  inner 
surface  of  the  bone,  as  well  as  the  adjacent  dura  mater.  This 
method  of  practice  the  author  would  })ursue  in  every  case  of  ex- 
tensive dei)ression  of  the  cranial  wall,  which,  if  unrelieved,  must 
entail  a  future  deformity  of  the  inner  and  outer  surfaces  of  the 
skull.* 

The  treatment  which  has  been  detailed  is  only  applicable  to 
fractures  in  the  superior  and  lateral  parts  of  the  cranium;  but  if 
the  injury  be  in  the  base,  its  inaccessibility  will  place  it  out  of  the 
reach  of  any  direct  surgical  treatment.  The  character  of  such 
fracture,  owing  to  the  injured  part  being  invisible,  can  only  be 
inferred;  and  here  the  surgical  management  is  restricted  in  its 


FRACTURE    OP    THE    CRANIUM.  171 

Sphere  of  action  and  has  only  occasional  opportunities  for  indirect 
intervention.  For  example,  where  there  is  a  profuse  escape  of  the 
cerebro-spinal  fluid  from  the  ear  or  nose,  resulting  from  injur}^  of 
the  petrous  part  of  the  temporal  bone  or  the  body  of  the  sphen- 
oid, then  an  attempt  should  be  made  to  arrest  the  discharge. 
This  should  be  tried  by  plugging  or  tamponing  the  outlet  of  the 
fluid;  if  this  be  from  the  ear,  the  meatus  should  be  plugged  with 
lint  saturated  with  some  astringent,  such  as  a  solution  of  gallic 
acid,  alumen,  or  some  salt  of  zinc  or  iron.  Or  if  the  fluid  should 
escape  from  the  anterior  or  j)Osterior  openings  of  the  nostrils, 
indicating  the  escape  of  fluid  through  the  sphenoid  bone,  or  pos- 
sibly through  the  Eustachian  tube  from  the  tympanic  cavity, 
then  an  effort  should  be  made  to  arrest  this  by  tamponing  the 
nostrils  before  and  behind  by  means  of  astringent  lint.  If  the 
fluid  be  thus  arrested  for  a  day  or  two,  then  it  is  possible  that 
the  breach  in  the  base  of  the  skull  might  become  closed,  and 
further  escape  of  fluid  be  prevented.  When  the  escape  is  from 
the  ear,  as  a  co-adjuvant  to  plugging,  one  might  first  inject  an 
astringent  solution  into  the  auditory  canal,  and,  perhaps,  thus 
directly  plug  the  fissure  in  the  petrous  bone.  Where  the  serous 
discharge  is  small  in  quantity,  and  has  its  probable  origin  in 
serum  expressed  from  clotted  blood,  or  is  derived  only  from  the 
internal  ear,  then  no  treatment  is  required,  as  it  will  cease  spon- 
taneously. 

If,  instead  of  serum,  the  escaping  fluid  be  blood,  then  its  arrest 
is  more  urgently  demanded,  since  the  amount  lost  may  be  so 
great  as  to  destroy  life.  An  astringent  solution  should  be  injected 
into  the  ear,  if  the  blood  issue  thence,  and  afterwards,  the  meatus 
should  be  carefully  plugged.  In  this  way  a  clot  will  be  formed 
which  will  extend  into  the  open  vessel  and,  possibly,  occlude  the 
rent  in  it,  until  healing  occurs.  Or  if  the  bleeding  be  from  the 
nose,  then  the  nostrils  in  front,  and  the  choanse  behind  should  be 
tamponed  with  lint  saturated  with  some  astringent.  The  astrin- 
gent solution,  if  not  antiseptic,  should  be  rendered  so  by  the  addi- 
tion of  corrosive  sublimate,  viz.,  one  in  three  thousand.  By  these 
means  severe  hsemorrhage  from  the  ear  or  nose  due  to  cranial 
fracture,  might  be  controlled.  The  tampon  should  be  renewed 
and  a  new  one  substituted  from  time  to  time.  Instead  of  the 
astringents  mentioned,  the  tincture  of  iodine  may  be  used,  and  the 
tamponing  material  saturated  with  it;  the  same  may  be  used  in 
the  auditory  canal  before  the  latter  is  plugged  up.  The  tincture 
of  iodine  coag-ulates  the  albumen  in  the  blood,  in  a  manner  simi- 


172  CKANIUM. 

lar  to  an  astringent,  and  it  has  a  less  corrosive  action  on  the 
parts  with  which  it  is  in  contact.  Such  clot,  probably,  after  par- 
tial absorption,  undergoes  organization  and  may  aid  in  closing 
the  fissure  or  cleft  in  the  broken  bone. 

After  recovery  from  a  fracture  at  the  base  of  the  skull,  it  is 
probable  that  the  patient  will  be  maimed  in  some  way;  there 
may  remain  complete  or  ])artial  deafness;  and  with  this  there 
may  be  unilateral  facial  palsy.  And  so  there  may  be  lesion  of  one 
or  more  of  the  first  six  pairs  of  nerv'^es,  which  have  exit  through 
the  base.  Thus,  besides  deafness  mentioned,  the  sense  of  smell, 
sight,  common  sensation  of  the  face,  and  the  muscular  movements 
of  tlie  eye  may  be  interfered  with.  And  such  peripheral  lesion 
would  point  with  certainty  to  the  site  of  fracture.  Recovery  from 
sucli  sensory  or  motor  lesion  could  not  be  facilitated  by  any  pro- 
cedure now  known  to  surgery.  Tlio  patient  might  be  consoled 
with  the  slight  and  delusive  hope  that  in  time  the  parts  might 
accommodate  themselves  to  the  pressure;  or  tliat  if  the  pressure 
were  due  to  a  coagulum,  tiiis  might  be  absorbed;  and  to  favor 
such  absorption,  some  aid  might  be  derived  from  large  doses  of 
the  iodide  of  potassium. 

GUNSHOT    WOUNDS    OF    THE    CRANIUM. 

Tlie  history  of  fracture  of  the  skull  which  precedes  will  con- 
clude with  an  additional  chapter  devoted  to  gunshot  wounds;  the 
individuality  of  these  injuries  entitles  them  to  a  special  consider- 
ation. 

Missiles  propelled  by  some  explosive  compound,  of  which  gun- 
powder is  the  most  common  one,  are  in  infinite  variety;  as  tliey 
vary  in  form,  volume,  and  velocity  of  movement,  so  the  violence 
done  by  them  differs.  The  difference  in  lesion  varies  from  the 
slight  marring  caused  by  grains  of  powder,  to  that  arising  from 
an  exploding  bomb,  or  shot  of  large  surface  and  great  weight; 
from  a  superficial  deformity  to  an  instant  destruction  of  the  victim; 
and  of  these  varying  forms,  wounds  caused  by  missiles  of  small 
size  chiefly  engage  the  attention  of  the  civil  surgeon.  On  the 
battle-field,  wounds  from -large  projectiles  are  seen ;  in  civil  life 
the  missile  from  the  pistol  or  rifle  is  the  usual  agent  of  sucli  wound; 
and  wounds  inflicted  by  these  weapons  upon  tlie  skull  are  the 
ordinary  ones  requiring  the  surgeon's  care;  those  from  larger  guns 
and  explosive  projectiles  are  more  rare,  and,  as  a  rule,  are  speedily 
fatal. 

Gunshot  wounds  made  on  the  cadaver  are  equal  in  severity  to 


GUXSHOT    WOUXDS    OF    THE    CKAXIUM.  173 

those  made  on  the  Kving  body.  Accuracy  in  shooting  is  rarely 
attained  with  the  revolver;  and  even  though  the  instrument  be 
rested,  yet  the  mark  is  often  missed.  A  shot  fired  from  this 
weapon  at  a  distance  of  forty  inches,  leaves  no  marks  of  powder; 
but  at  the  distance  of  sixteen  inches,  stains  are  made  by  the 
powder.  At  the  distance  of  seventy-five  feet,  small  shot  pene- 
trates but  slightly;  but  at  the  distance  of  five  feet  and  a  half,  the 
shot  penetrates,  yet  no  marks  are  made  by  the  powder.  The  exit 
opening  is  greater  than  the  entrance  point.  At  the  distance  of 
five  feet,  small  shot  does  more  violence  than  a  bullet  fired  through 
the  same  distance. 

Stains  of  different  character  are  produced  by  different  kinds 
of  powder.  Fine  powder  leaves  but  little  marking  or  burning; 
powder  which  contains  much  sulphur  is  more  violent  in  its 
action. 

The  gunshot  wound  of  the  cranium  presents  itself  in  two  lead- 
ing forms;  in  the  one  class  the  scalp  is  not  opened,  the  injury  to 
the  cranial  wall  being  wholly  subcutaneous;  but  in  the  second 
class,  along  with  the  osseous  wound,  there  is  also  a  lesion  of  the 
scalp.  Experimental  work  illustrating  the  action  of  the  gunshot 
projectile  on  the  human  body  has  been  done  and  reported  upon 
by  several  surgical  writers.  On  the  cranial  gunshot  wound,  one 
of  the  ablest  and  most  trustworthy  rej^orts  has  been  made  03^ 
Teevan;  later,  reference  will  be  made  to  the  same.  In  1875 
Crespi  and  Tazon  published  some  general  observations  in  tliis 
field,  of  which  the  subjoined  is  a  summary.  The  ball  or  projectile 
from  oblique  or  glancing  contact  with  the  head  may  cause  no 
external  wound,  yet  produce  a  fracture  of  the  cranial  wall;  and 
this  fracture  may  be  very  extensive  and  even  destroy  life,  though 
the  seal  J)  is  unopened.  Such  wound  can  only  arise  from  a  large 
ball;  a  smaller  one  will  wound  the  scalp,  and  if  it  pass  deeper 
than  the  latter,  it  will  also  wound  the  skull.  As  wounds  of  the 
wall,  which  then  arise,  diverse  forms  present  themselves,  of  which 
we  will  mention  the  following  leading  ones : — 

1.  The  ball  may  penetrate  the  scalp,  and  at  the  same  time 
carry  the  clothing  with  it  which  it  does  not  penetrate,  and,  hav- 
ing reached  the  skull,  it  may  rebound  and  be  withdrawn  with  the 
clothing;  in  such  a  case  the  bone  is  only  superficially  injured. 
Or  without  any  intermediate  clothing,  the  missile,  having  been 
spent  or  lost  its  speed,  enters  the  uncovered  scalp,  impinges  on 
the  bone  and  then  rebounds  through  the  same  wound. 

2.  The  missile  may  enter  the  scalp,  and,  having  channeled  a 


1/4-  CKANILM. 

slight  furrow  in  the  surface  of  the  skull,  it  stops  and  remains 
buried  in  the  scalp;  or  it  may  escape  from  the  scalp  at  some  i)oint 
near  by.  The  open  canal,  then  formed,  will  lie  partially  in  the 
cranial  wall,  and  the  gravity  of  the  injury  will  then  depend  on 
the  depth  of  the  furrow  in  the  wall.  The  furrow  may  be  deep 
enough  to  fracture  and  detach  a  fragment  from  the  inner  plate; 
and  such  shot-wound,  though  it  does  not  directly  pierce  the  wall, 
yet  it  is  more  perilous,  iierliai».s,  than  one  which  pierces  quite 
through  the  wall;  for  the  loose  fragment  of  irregular  form  may 
act  more  deleteriously  than  would  tlie  ball  itself. 

3.  The  ball  may  enter  the  cranium,  and,  having  })ursued  a 
straight  route,  it  may  lodge  within  the  brain,  or  at  the  opposite 
wall  of  the  skull  wliich  remains  uninjured;  or  instead  of  passing 
straight  into  the  brain,  it  may  be  deflected  by  the  dura  mater  and 
pursue  a  curved  line  along  the  inner  surface  of  the  skull,  and 
lodge  in  contact  with  the  skull,  without  having  opened  the  men- 
ingeal envelope  of  the  brain. 

4.  The  ball  may  fracture  and  pass  through  the  cranial  wall, 
and,  having  traversed  the  brain  in  a  straight  direction,  it  may 
break  and  pass  through  the  opposite  wall  of  the  skull;  in  this 
form  tliere  is  a  straight  shot-canal  tlirough  the  head.  It  is  pos- 
sil)le  in  this  last  case,  that  the  missile  having  passed  through  the 
second  wall  may  lodge  beneath  the  scalp;  and  there  would  then 
remain  a  blind  canal,  with  a  ball  at  the  bottom  of  it. 

To  sum  up,  the  cranial  sliot  M^ound  may  present  itself  in  one 
of  the  following  forms:  wound  by  simple  contact,  in  the  form  of 
a  furrow,  a  blind  canal,  or  in  the  form  of  a  complete  canal  Dass- 
ing  through  the  head. 

The  diagnosis  is  commonly  easily  made,  since  the  history  of 
the  case,  in  which  a  firearm  was  used  by  the  patient  or  some  one 
else,  clearly  reveals  the  causal  agency  of  the  wound.  In  deter- 
mining the  fact,  one  may  be  assisted  by  the  presence  of  marks 
about  the  wound  in  the  integument;  also,  the  form  of  the  wound 
can  aid.  The  extent,  direction,  depth  and  character  of  the  wound 
must  be  learned  by  the  use  of  the  probing  sound.  The  sound 
judiciously  used,  carries,  as  it  were,  both  an  eye  and  a  finger  into 
the  wounded  structures,  so  that  the  searcher  learns  the  condition 
of  the  injured  parts. 

Nearly  connected  with  the  diagnosis  are  the  openings  which  the 
ball  makes  in  entering  and  escaping  from  the  wounded  parts.  The 
form  of  the  ball  and  speed  with  which  it  is  moving  determine  the 
character  of  these  openings;  also,  the  'distance  which  the  ball  has 


GUXSHOT    WOUNDS    OF    THE    CEAXIUM.  175 

traveled  before  striking,  influences  the  form  of  tlie  wound. 
Simon  of  Darmstadt,  in  1850,  made  a  series  of  experiments  on 
this  subject;  his  work  consisted  in  shooting  at  animals  and 
masses  of  flesh  at  short  and  long  range.  He  found  that,  at  short 
distance,  a  ball,  moving  with  great  velocity,  formed  openings  at 
its  entrance  and  exit  whicli  were  exactly  alike.  In  case  the  ball 
is  moving  less  rapidly,  then,  at  its  entrance,  it  cuts  out  a  section  of 
the  wounded  structure  equal  to  the  size  of  the  missile.  This  was 
demonstrated  by  catching  the  material  that  was  cut  by  the  ball 
on  paper  properly  placed.  And  in  this  case,  the  margins  of  the 
entrance  point  are  contused,  ecchymosed,  and  the  edges  are 
inverted;  meantime,  the  exit  opening  is  less  round  than  that  of 
entrance;  besides  it  is  torn  and  everted.  But  if  the  ball  traversed 
the  part  obliquely,  these  diagnostic  differences  are  less  marked; 
and  if  clothing  surround  the  part  which  is  pierced  obliquely,  then 
the  entrance  through  the  clothing  will  be  round,  with  loss  of 
structure,  while  the  exit  point  will  be  triangular,  or  slit-like. 
After  healing  the  entrance  point  is  round  and  depressed,  while 
that  of  the  outlet  will  present  a  scar  uplifted  and  slit-like  in 
form. 

Simon  found  that,  in  the  soft  parts,  the  exit  opening  ma}'  be 
larger  than  that  of  entrance,  when  fragments  of  bone  have  been 
detached  and  are  carried  along  with  the  ball;  the  same  is  the 
case  when  the  ball  has  been  flattened  and  enlarged  in  surface  by 
contact  with  a  bone. 

The  diagnosis  of  the  entrance  and  exit  openings,  left  by  a  ball 
in  traversing  the  cranial  wall,  has  been  greatly  aided  by  the 
experiments  of  Teevan  of  London,  which  will  long  remain  as  a 
model  of  excellence  amidst  the  vast  array  of  experimental  work, 
which  has  been  done  to  illustrate  the  character  of  violence  done 
by  the  gun-powder  missile  on  the  human  body. 

In  these  experiments,  made  in  1864,  Teevan  found  that,  by 
firing  from  a  short  distance  straight  at  a  skull,  the  entrance 
through  the  outer  plate  of  the  cranial  wall  will  corre.spond  to 
the  size  of  the  ball,  and  the  fracture  will  be  smooth  and  without 
fissure  or  splinter;  but  the  opening  through  the  inner  plate  will 
be  larger  than  the  one  tlirough  the  outer  one,  and  the  orifice 
will  be  smooth  and  not  fissured.  If  the  ball  be  fired  through  the 
foramen  magnum,  then  those  conditions  will  be  reversed;  the 
outer  plate  will  have  a  larger  orifice  than  tne  inner  one.  The 
plate  first  impinged  on  and  broken,  shows  the  exact  form  of  the 
traversing  ball. 


170  CRANIUM. 

The  form  of  the  ball  has  its  influence;  a  larger  exit  orifice  is 
made  by  a  round  ball  than  by  a  conical  one;  the  round  ball 
produces  a  round  0})ening,  while  the  conical  one  makes  a  conical 
or  elliptical  one. 

A  ball,  fired  from  a  barrel  of  smooth  bore,  loses  much  more 
of  its  speed,  in  traversing  a  body,  th^n  does  one  which  has  been 
fired  from  a  rifled  barrel. 

In  traversing  the  skin,  the  inversion  and  eversion  of  the 
openings  correspond  to  the  direction  pursued  by  the  ball. 

If  a  round  ball  be  fired  obliquely  against  the  skull,  it  glances 
off;  but  if  the  ball  be  conical,  it  will  nearly  always  enter  the 
skull;  and  having  been  flattened  by  the  impact,  it  will  cause  more 
violence  than  if  fired  perpendicularly. 

If  the  skull  be  pierced  by  something  other  than  a  ball,  vio- 
lence, similar  in  character,  is  done.  For  example,  if  it  be  caused 
by  a  nail  or  the  edge  of  an  axe,  then  the  opening  in  the  outer 
plate  will  represent  the  entering  object,  while  the  inner  plate  will 
be  opened  more  extensively. 

In  firing  through  two  boards,  which  are  near  each  other,  the 
exit  opening  was  larger  than  that  of  entrance,  due  to  the  ball 
having  carried  along  w'ith  itself  particles  of  wood,  which  increased 
its  volume. 

The  experiments  of  firing  at  the  skull  were  varied  in  several 
ways.  For  example,  the  firing  was  done  from  the  inside,  and 
through  the  wall  where  one  lamella  had  been  removed  by  tre- 
phining, and  the  conclusion  arrived  at  was  that  the  missile,  in 
traversing  one  lamella,  carries  particles  with  it,  which  enlarge  its 
volume,  so  that,  when  it  passes  through  the  next  lamella  or  wall 
it  opens  a  larger  orifice. 

The  foregoing  points,  concerning  the  entrance  and  exit  open- 
ings of  the  missile  and  the  changes  in  form  which  it  undergoes, 
are  important  subjects,  which  closely  concern  the  student  of 
Forensic  Medicine;  for  the  determination  of  the  agent  or  person, 
who  inflicts  the  wound,  ma}'  depend  on  the  peculiarities  and 
forms  of  the  wound  which  hq,ve  here  been  detailed;  and  thus 
might  be  unraveled  the  facts  whether  the  wound  was  self-caused, 
or  made  by  the  hand  of  an  assailant. 

A  careful  search  should  be  made  to  discern  whether  the  ball  has 
passed  through  .some  article  of  the  dress  of  the  patient,  and  carried 
and  lodged  fragments  of  the  same  in  the  wound;  hence  clothing, 
which  may  have  been  traversed,  should  be  inspected,  and,  if  it  be 
presumable  that  such  fragments  remain  in  the  shot-canal,  an 


GUNSHOT    WOUNDS    OF    THE    CRANIUM.  177 

endeavor  should  be  made  to  extract  the  same;  for  such  foreign 
matter  acts  much  more  deleteriously  than  the  ball  itself 

In  regard  to  the  danger  and  fatality  of  wounds  of  the  cranium, 
there  is  ample  material  to  draw  correct  conclusions  from,  fur- 
nished by  the  surgical  reports  of  the  Northern  army,  during  the 
War  of  the  Rebellion,  in  the  United  States.  These  statistics  cost 
an  immense  amount  of  labor,  as  well  as  the  life  of  the  compiler, 
Dr.  Otis,  who  fell  a  victim  to  overwork.  From  these  voluminous 
records,  the  following  facts  are  extracted.  Of  gunshot  wounds  of 
the  cranium  without  depression,  there  were  2,911  cases;  of  these, 
there  died  1,826,  that  is,  64.6  per  cent.  There  were  364  cases  in 
which  there  was  depression,  and,  of  these,  there  died  129,  that  is, 
35.8  per  cent.  From  this,  it  singularly  appears  that  depression 
acted  conservatively  in  gunshot  wounds  of  the  skull.  The  only 
explanation  which  can  be  offered  of  these  facts,  so  contradictory 
to  what  inexperience  would  have  predicted,  is  that  the  violence 
done  in  the  latter  series  of  figures  was  less  than  that  done  in  the 
former  series. 

Since  the  era  of  antiseptics,  the  mortality  of  all  injuries  of  the 
cranium,  including  also  gunshot  wounds,  has  undergone  a  mate- 
rial revision.  According  to  Estlander,  the  Finnish  surgeon,  who 
has  studied  the  subject,  before  1870,  the  mortality  of  wounds,  in 
wliicli  the  skull  is  laid  bare,  was  twenty -four  per  cent;  but  since 
1870,  under  antiseptic  management,  the  number  of  deaths  has 
been  reduced  to  one  and  one-half  per  cent.  Prior  to  1870,  the 
mortality,  in  cases  in  M'hich  the  scalp  has  been  opened  and  the 
cranium  fractured,  was  near  sixty-seven  per  cent;  but  since  that 
time,  five- sixths  of  such  cases  recover.  But  where  the  fracture  is 
in  the  base  of  the  skull,  that  is,  cases  in  which  the  antiseptic 
treatment  is  not  applicable,  the  mortality  now  is  the  same  as 
formerly. 

In  1879,  a  series  of  figures  was  collected  by  Gurlt,  bearing  on 
the  fatality  of  wounds  in  which  a  foreign  body  enters  the  cranium, 
and  which  shows  that,  of  three  hundred  and  sixteen  cases,  one 
hundred  and  sixty  recovered,  and  one  hundred  and  fifty-six  died. 
In  one  hundred  and  six  of  the  cases,  the  body  was  extracted,  and 
of  these,  thirty-four,  or  about  one-third,  died;  while  in  two  hun- 
dred and  ten  cases,  in  which  no  effort  was  made  to  extract  the 
body,  one  hundred  and  twenty-two  died,  that  is,  somewhat  more 
than  one-half. 

In  the  history  of  gunshot  wounds  of  the  cranium,  Fritz  finds 
that  more  recoveries  liave  occurred  in  cases  in  which  there  has 


178  ci:amlm. 

been  but  little  or  no  surgical  interference.  The  young  subject, 
with  such  injury,  is  more  ni)t  to  recover  than  the  old  person.  He 
finds  that  cranial  injury  becomes  more  perilous  as  it  invades  the 
sides  and  base  of  the  skull. 

Cranial  gunshot  wounds  are  least  dangerous  when  i)roduced 
by  small  balls.  Klister,  in  1882,  reported  cases  in  which  small 
balls  entered  the  cranium;  the  wound  in  the  seal])  was  enlarged 
and  osseous  fragments  removed,  but  the  ball  was  not  extracted. 
The  cases  recovered.  Bergmann  advises  not  to  open  the  wound, 
nor  remove  osseous  fragments,  but  to  treat  such  as  simple  wounds. 
Langenbeck  treated  five  cases  of  cranial  gunshot  wounds,  in  which 
a  small  ball  had  entered  the  skull.  These  cases  recovered  with- 
out any  active  treatment.  Bardeleben  also  reports  cases,  in  which 
there  was  recovery,  witliout  removal  of  the  ball  which  had  entered 
the  skull. 

Balls  of  large  volume  have  frequently  entered  the  cranial 
cavity  and  penetrated  the  brain  without  causing  death;  as  a  rule, 
liowever,  in  such  cases  there  has  occurred  some  impairment  of 
the  subject's  intellect,  or  lesion  of  sensation  or  motion.  Where  a 
ball  remains,  the  most  favorable  event  that  can  ensue  is  that  it 
become  encysted,  that  is,  that  it  become  inclosed  and  held  in 
its  new  position  by  firm  material  which  is  similar  to  cicatricial 
tissue.  Such  a  ball  may  remain  innocuous  for  an  indefinite 
period.  A  much  more  unfavorable  event  is  that  in  which  the 
ball  forsakes  the  site  in  which  it  is  lodged;  and  when  this 
occurs  in  the  soft  substance  of  the  brain,  the  ball  may  sink 
directly  downwards,  or  in  that  direction  in  which  it  meets  with 
the  least  resistance.  Thus  gravitating,  the  ball  may  travel  w'holly 
away  from  its  |)riniary  place  of  lodgment:  and  in  its  migration 
it  injures  the  parts  witli  which  it  comes  into  contact,  and,  thus, 
the  gravity  of  the  pi'imary  wound  is  much  increased.  Such 
migration  may  occur  immediately,  or  it  may  ensue  at  a  much 
later  period;  and  in  the  latter  case,  the  ball  quits  the  encysting 
structures  by  which  it  had  previousl}'  been  held  in  place.  From 
these  facts,  it  is  apparent  that  when  a  ball  has  lodged  in  the  cra- 
nial cavity,  it  becomes  an  enduring  element  of  danger,  which  will 
ever  afterwards  menace  the  life  of  the  patient;  and  though  such 
body  has  remained  for  a  long  time  without  giving  trouble,  yet 
there  is  no  certainty  that  it  will  continue  to  do  so;  and,  hence,  the 
rule  to  be  observed  in  all  cases,  in  which  the  ball  is  large,  is  to 
attempt  to  extract  it  when  this  can  be  done  without  greatly  add- 
inef  to  the  wound  alreadv  existing. 


GUNSHOT    WOUNDS    OF    THE    CRANIUM.  179 

Treatment. — As  the  extent  and  gravity  of  cranial  wounds  vary, 
so  their  treatment  must  differ. 

In  the  first  class  of  wounds  in  which  the  projectile  or  ball  has 
not  opened  the  scalp,  and  still,  from  glancing  impact,  the  cranium 
has  been  fractured,  the  extent  of  the  fracture  can  only  be  infer- 
entially  determined  through  palpation  and  the  condition  of  the 
patient.  Since,  frequently,  the  fracture  is  on  a  large  scale,  and 
consists  of  a  number  of  fragments  which  are  loose,  in  such  cases 
these  fragments  can  be  pressed  inwards  or  moved  by  palpation, 
and  the  gravity  of  the  injury  fairly  estimated.  Besides,  the  state 
of  the  patient,  as  respects  mentality,  sensation  and  motion, 
aj^proximately  indicates  the  anjount  of  injury  which  he  has 
received ;  and  this  is  often  so  great  that  any  active  surgical  inter- 
ference, instead  of  benefiting  the  patient,  would  rather  disturb 
the  quiet  which  should  be  the  privilege  of  the  dying  man. 
Where  there  is  great  depression  and  other  symptoms  denoting 
serious  if  not  fatal  lesion  of  the  brain,  then  the  primary  care  of 
the  wounded  person  should  be  limited  to  giving  him  a  stimulant, 
and  the  use  of  means  designed  to  restore  and  maintain  the  tem- 
perature of  the  body.  Should  the  patient,  however,  rally  and 
present  signs  that  his  case  is  not  hopeless,  then  attention  should 
be  turned  to  his  injury.  If  there  be  marked  depression  of  bone, 
or  a  fragment,  perhaps,  has  been  displaced  beneath  another,  or 
forced  under  the  undepressed  margin  of  the  adjacent  wall,  then 
the  broken  bones  should  be  exposed  by  incision,  and  the  depressed 
part  uplifted.  Likewise,  through  such  incision  any  fragments 
which  are  found  to  be  quite  detached  from  the  periosteum  and 
dura  mater,  should  be  removed;  for  such  loose  pieces  of  bone 
would  act  as  foreign  bodies  and  prevent  recovery.  But  if  a  frag- 
ment has  sufiicient  attachment  to  adjacent  parts  to  insure  its 
vitality,  then  it  should  not  be  removed.  After  the  removal  oi 
loose  fragments,  and  the  elevation  of  the  depressed  cranial  wall, 
the  wound  made  should  be  closed  by  suture  except  at  a  depend- 
ent point,  where  a  drainage  tube  is  inserted  and  allowed  to 
remain  for  some  days,  for  the  escape  of  fluid  detritus  from  tlie 
wound.  Such  wound  should  be  covered  by  a  protective  compress 
of  lint  which  has  been  saturated  with  a  dilute  alcoholic  solution; 
and  this  should  be  retained  cold  by  a  light  overlying  ice-bag. 
And  should  signs  of  cerebral  trouble  appear,  these  should  be 
combated  b}^  means  described  under  the  head  of  meningitis  and 
encephalitis. 

In  the  second  group  of  wounds,  in  which  the  missile  opens  the 


180  CKAXIIM. 

scalp,  we  will  first  notice  the  simplest  form,  in  which  the  ball 
merely  comes  in  contact  with  the  cranium  and  communicates 
but  slight  violence  to  the  bone.  The  injury  then  will  differ 
according  as  the  ball  merely  grazes  the  surface  in  passing  or, 
having  exhausted  its  motion,  it  lodges  as  a  spent  ball  against  the 
wall.  In  the  first  case,  the  injury  done  will  be  confined  wholly, 
or  nearly  so,  to  the  soft  parts;  and  tlien  the  treatment  would  be 
a  simple  matter,  being  similar  to  that  of  an  incision  or  simple 
breach  of  the  scalp.  And  so  in  the  second  case,  in  which  the 
ball  is  an  inert  missile  lodged  against  the  wall,  the  treatment 
would  be  limited  to  that  of  a  slight  wound  of  the  scalp;  but  as 
the  full  extent  of  tiie  violence  done  is  a  matter  of  uncertain  con- 
jecture, the  case  should  be  thoughtfully  watched;  and  should 
other  symptoms  arise,  the  latter  should  receive  approi)riate  atten- 
tion. Where  severe  internal  complications  appear,  and  sliow 
that  the  gravity  of  the  injury  was  not  fully  estimated,  then  it  will 
probably  become  necessary  to  use  the  trephine. 

In  the  wound  of  the  next  grade,  in  which  the  passing  ball 
has  touched  and  broken  the  surface  of  the  cranium,  then  the 
wound  should  be  examined,  and  the  detached  or  partly  detached 
fragments  sliould  be  removed;  and  the  further  treatment  of  the 
wound  should  be  similar  to  that  before  detailed  for  injury  of  the 
scalp.  As  in  the  case  of  simple  contact,  the  amount  of  internal 
injury  done  is  not  always  known,  so,  in  tlie  case  of  the  superficial 
furrowed  wound  of  the  wall,  there  may  be  injury  to  the  subjacent 
dura  mater;  and  the  evidence  of  this  will  only  appear  at  a  later 
time.  Hence  the  need  of  heedful  attention  to  any  indication  that 
may  point  towards  intra-cranial  complication;  such  complication 
would  probably  arise  from'  a  fracture  of  the  vitreous  plate;  the 
loosened  piece  of  bone,  deprived  of  nutrition,  would  die  and  act 
as  a  foreign  body  of  uneven  surfaces.  In  such  a  case,  trephining 
would  furnish  the  only  means  of  relief,  and,  the  earlier  this  were 
done,  the  greater  would  be  the  relief  to  the  patient. 

In  the  next  form  of  gunshot  wound,  in  which  there  is  but  one 
opening,  the  missile  may  carry  along  with  itself  fragments  of 
clothing,  hair,  minute  portions  of  the  scalp  and  one  or  more 
fragments  of  bone.  As  a  rule,  the  ball  will  Ije  found  within  the 
skull;  yet,  as  Guthrie,  an  eminent  Englisli  authority  in  military 
surgery,  remarks,  this  is  not  always  so.  The  ball  may  strike  the 
cranium  and  fracture  and  force  inwards  a  fragment  of  the  wall^ 
and  yet  the  projectile  may  rebound  and  not  enter  the  skull.  In 
such  case  the  finger  or  sound  can  pass  into  the  track  of  the  wound. 


GUNSHOT    WOUNDS    OF    THE    CRANIUM.  181 

and,  finding  a  piece  of  bone  nearly  the  size  of  the  ball,  this  frag- 
ment can  easily  be  mistaken  for  the  ball;  such  a  condition  would 
greatly  embarrass  diagnosis,  since,  though  the  fragment  of  bone 
is  removed,  the  surgeon  could  not  be  sure  that  the  ball  was  not 
lodged  somewhere  in  the  head. 

As  the  instances  are  very  rare  in  which  the  ball  rebounds  from 
the  breach  that  it  makes,  hence  no  pains  should  be  spared  in  a 
diligent  search  for,  and  the  extraction  of,  the  missile  when  found. 
The  hope  that  the  ball  may,  when  not  removed,  become  encysted, 
and  in  such  state  remain  inert  and  harmless,  is  doubted  by  Bill- 
roth, who,  in  1870,  announced  a  contrary  opinion.  He  claims 
that  from  the  irregular  and  battered  shape  which  the  ball  often 
acquires,  it  is  apt  to  induce  suppuration.  From  its  impact  with 
the  bone,  the  ball  becomes  roughened  in  form,  and  sometimes 
split  into  two  parts.  The  striking  of  the  ball  against  a  bone  can 
also  cause  inflammation  of  the  latter.  Billroth  saw  cases  in  which 
round  balls  caused  suppuration,  due,  he  thinks,  to  laceration  of 
the  tissue  by  the  heavy  body;  and  had  the  ball  been  smaller  and 
lighter,  probably  no  suppuration  would  have  arisen. 

As  the  ball  usually  carries  along  with  itself  and  leaves  behind, 
either  in  or  at  the  side  of  its  track,  pieces  of  clothing  and  frag- 
ments of  bone,  the  first  work  of  extraction  should  be  directed  to 
the  removal  of  these  bodies;  for  their  presence  would  be  quite  as 
detrimental  to  the  encephalic  structures  as  the  ball  itself  ^For 
the  removal  of  these  foreign  matters,  Betz  invented  a  sound 
which  terminated  in  a  hook-like  end,  which  must  be  short,  not 
more  than  a  line  long;  such  a  sound  may  be  made  of  silver, 
attenuated  at  one  end,  and  bent  there  at  right  angles.  The 
advantages  claimed  for  such  a  sound  are  that,  without  making 
any  incision,  the  fragments  can  be  caught,  even  if  they  lie  trans- 
versely, and  thus  much  more  easily  removed  than  can  be  done 
with  forceps.  In  the  absence  of  this  instrument,  one  similar  to  it 
might  be  extemporized,  viz.,  a  long  silver  probe,  bent  at  one  end. 
The  extraction  might  also  be  accomplished  with  a  pair  of  long, 
narrow-bladed  forceps,  similar  to  those  used  in  operations  on  the 
eye. 

The  ball,  when  lodged  inside  of  the  skull,  penetrates  deeper 
than  the  foreign  materials  just  mentioned;  and  as  it  has  insufii- 
cient  momentum  to  bear  it  through  the  head,  its  lessened  speed 
permits  of  deflection;  and  then,  wandering  from  a  straight  direc- 
tion, its  detection  becomes  difficult.  For  this  work  various  sounds 
have  been  devised;  such  an  instrument  may  be  wholly  of  metal 


182  (RAXIIM. 

or  gutta  porclia,  modelod  somewhat  after  tlie  form  of  a  iiretliral 
sound;  ami  this  is  improved,  if  the  sound  be  armed  with  a  point 
of  metal,  ivory  or  })orcelain.  The  sound  with  ivory  or  porcelain 
point  was  invented  by  Xelaton,  and  enabled  him  to  discern,  by  the 
trace  of  lead  left  on  the  sound,  the  bullet  in  Garibaldi's  ankle. 
Instead  of  this,  the  author,  in  a  case  of  cranial  gunshot  wound, 
used  a  probe  extemporized  on  the  spot  from  a  piece  of  white  pine 
wood.  This  wood,  as  readily  as  porcelain,  can  receive  and  bring- 
back  a  trace  of  the  leaden  ball.  The  work  of  finding  the  missile 
is  often  no  easy  feat,  even  for  the  most  experienced  hand.  xVlso, 
without  ])i'evious  training  and  thoughtful  management  of  the 
searching  sound,  not  only  will  the  ball  not  be  discovered,  but 
injury  will  be  added  to  that  already  existing.  Injudicious  or 
careless  manipulation  may  carry  the  probe  beyond  the  ball,  and 
thus  the  wound  is  made  deeper;  or  the  ball  may  be  pushed 
onward  into  the  brain,  and  thus  the  shot  canal  can  be  extended. 
The  fruitless  efforts,  made  by  distinguished  military  surgeons,  to 
discover  the  bullet  in  the  ankle  of  (Jaribaldi,  fully  illustrate  the 
difficulties  attendant  on  probing  for  a  bullet.  The  art  attained 
by  experience,  and  tlie  secret  possessed  by  him  who  successfully 
probes,  consists  of  slowness  and  gentleness  combined  with  thought- 
ful tact  in  the  use  of  the  sound. 

Considering  the  difficulty  that  is  experienced  in  discovering 
the  ball,  it  is  evident  that  there  would  be  a  special  advantage  in 
having  an  instrument  in  which  were  combined  both  probe  and 
extractor;  such  an  instrument  is  presented  in  some  of  the  models 
of  bullet  forceps  which  have  been  jn-oduced  by  the  untiring  hand 
of  invention;  the  desire  to  present  something  new,  and  the  emu- 
lation to  outstrip  predecessors,  have  furnished  here,  as  in  other 
sections  of  surgery  in  which  instruments  are  needed,  a  multitude 
of  specimens.  One  of  the  best  forceps  for  finding  and  at  once 
removing  the  bullet,  is  one  having  sharp-toothed  blades,  of  which 
each,  when  detached,  resembles  a  tenaculum.  The  handles  are 
long,  and  the  joint,  by  which  they  are  riveted  and  locked  together, 
is  placed  at  a  considerable  distance  from  the  points  which  seize; 
this  distance  from  the  joints  permits  of  the  points  being  widely 
separated,  so  that  a  much  larger  body  can  be  grasped  than  could 
be  done  if  the  joint  were  near  the  end.  When  the  ball  has  been 
touched  with  the  instrument,  the  booklets  of  the  latter  can  be 
made  to  fix  themselves  in  the  missile;  and,  as  withdrawal  is  done, 
the  Ijall  is  movable  in  the  mouth  of  the  forceps,  and  so  adapts 
itself  to  the  canal  that  the  removal  is  more  readily  done  than  if 


GUNSHOT    WOUNDS    OF    THE    CRANIUM.  1S3 

the  ball  were  firmly  grasped.  This  instrument,  armed  as  it  is 
witli  firm-liolding  tentacles,  may  be  used  also  for  the  extraction 
of  fragments  of  clothing  and  other  materials  lodged  in  or  beside 
the  canal.  In  this  work  of  removing  foreign  bodies,  the  author 
will  repeat  the  warning  hitherto  given,  to  spare  the  encephalic 
structures. 

After  this  work  has  been  done,  the  edges  of  the  breach  in  the 
cranium  should  be  carefully  inspected,  and  if  there  be  depression, 
this  can  readily  be  rectified.  Also,  the  edges  of  the  opening 
should  be  observed,  and  if  fragments  be  found  there,  they  should 
be  removed.  As  the  ball  in  passing  through  the  wall  fractures 
the  inner  plate  more  than  the  outer  one,  hanging,  or  loose  frag- 
ments which  have  originated  from  the  inner  plate  should  be 
removed.  This  work  can  only  be  done  where  the  opening  is 
large,  and  admits  of  inspection  with  the  eye.  The  bone  frag- 
ments, bullet  and  other  foreign  material  having  been  extracted, 
attention  must  also  be  given  to  the  wounded  soft  parts.  Cerebral 
matter  oozing  from  the  wound  should  be  cleansed  away  by  a 
small  stream  of  aseptic  water  allowed  to  flow  over  the  part;  shreds 
of  the  wounded  dura  mater  must  be  trimmed  off,  so  that  a  sound 
edge  will  remain;  and  if  there  be  grains  of  powder  lodged  in  the 
wound  traversing  the  scalp,  the  powder-stained  edges  of  the 
wound  must  be  trimmed  off.  The  time  spent  in  these  tedious 
minutse  will  be  regained  manifold  in  the  accelerated  healing 
which  such  care  assures.  If,  however,  the  wound  is  a  clean, 
smooth  one,  and  there  be  no  pendent  fragments,  then  its  margins 
must  be  left  intact;  and  the  surgeon  will  proceed  to  the  external 
dressing.  As  preliminary  to  this,  the  part  should  be  cleansed 
with  a  carbolated  or  a  sublimated  solution.  Arrived  at  this 
point,  the  surgeon  must  select  his  course  of  treatment  from  the 
different  ones  which  have  been  advised.  The  nihilistic  tendency, 
which  is  seeking  to  overthrow  the  idols  long  venerated  in  the 
domain  of  internal  medicine,  has  its  advocates  also  in  the  surgi- 
cal management  of  the  gunshot  wound.  For  example,  Passavant, 
in  1871,  teaches  that  the  best  method  of  treating  such  wounds  is 
that  heralded  by  Bartscher  and  Burow,  in  which  the  wounds  are 
left  open  with  little  or  no  dressing.  The  author  does  not  counsel 
such  a  Fabian  course,  believing,  as  he  does,  that  total  inaction  is 
as  baneful  as  excessive  interference,  since  nature,  like  man  him- 
self, is  ill  tolerant  of  studied  neglect.  Roser,  in  the  management 
of  these  wounds,  while  deprecating  complicated  dressing,  would 
still  do  something;  he  would  not  sound,  irrigate  or  inject;  he  only 


184  CHANir.M. 

dresses  the  exLenial  wound  witli  carbolizcd  gauze;  in  this 
simple  Avay  lie  finds  that  the  shut  canal  will  often  heal.  Should, 
however,  the  wound  suppurate,  he  would  open,  dilate  with  lami- 
naria  and  then  introduce  a  tube  for  drainage.  It  is  probable,  how- 
ever, that  were  more  attention  primarily  given  to  the  wound, 
suppuration  would  be  averted,  or  much  reduced. 

Rejecting  then  a  nihilistic  course,  as  well  as  one  which  is 
nearly  akin  to  it,  the  author  would  carefully  note  the  condition 
of  each  case,  and.  unless  the  hall  had  been  so  small  that  it  had 
fractured  but  slightly  the  cranial  w^all,  he  would  prejiare  tiie 
wound  for  the  external  dressing  in  the  way  that  has  been 
detailed;  he  would  sound,  extract  the  missile  and  bony  fragments; 
and  this  completed,  he  would  introduce  a  drainage  tube  of  aver- 
age calibre,  so  as  to  permit  fluid  excreta  to  escape :  the  external 
wound  should  then  be  powdered  with  iodoform,  and  lastly,  over 
this  should  be  placed  a  lint  compress,  maintained  moist  w^ith  a 
carbolated  or  sublimated  solution.  And  to  maintain  the  head 
cool,  an  ice-bag  should  be  used;  or  instead  of  this  bag,  the  work 
may  be  well  done  by  means  of  a  tubular  helmet,  through  which 
there  is  constantly  circulating  a  current  of  cold  water;  by  this 
latter  contrivance,  the  cold  can  be  most  equably  distributed.  In 
large  canals  in  wdiich  the  drainage  is  maintained  through  a  tube, 
the  latter  should  he  allowed  to  remain  in  place  for  several  days; 
too  early  removal  has  been  the  cause,  here  as  elsewhere,  of  the 
accumulation  of  scro-i)uruleiit  matter,  which  imperatively  de- 
mands reoi^ening  of  the  wound.  In  brief,  it  is  seen  that  the 
blind  shot  canal  in  the  skull  is  to  be  treated,  after  it  has  been 
freed  from  foreign  material,  in  the  same  way  as  such  a  wound 
should  be  elsewhere. 

In  the  fourth  class  of  gunshot  wounds  of  the  cranium,  in  wJiich 
the  canal  has  both  entrance  and  outlet,  the  work  of  dressing  will 
be  more  simple  than  that  of  the  blind  canal.  First  of  all,  the 
openings  should  be  studied,  and  if  that  of  exit  be  smaller  than 
the  other,  then,  according  to  Demme,  it  is  probable  that  the  ball 
has  been  broken,  and  a  portion  of  it  remains  in  the  skull.  Among 
the  students  of  military  surgery  there  has  been  a  contest  whether 
the  leaden  ball  can  melt  through  heat  generated  b}"  impact  with 
bone,  and  there  seems  to  be  credible  evidence  that  sucli  fusion 
does  sometimes  occur;  thus  the  volume  of  the  ball  would  be 
diminished,  and  the  molten  material  might  then  lodge  on  the 
edge  of  the  entrance.  Meantime,  the  missile,  lessened  in  volume, 
would  produce  a  smaller  opening  at  its  outlet.     In  the  open  canal, 


TREPANATION.  185 

foreign  material  would  probaijly  lodge  near  the  exit  opening; 
iience  the  search  for  such  material  should  be  more  diligent  at 
that  point.  Demme  likewise  noted  a  difference  in  the  liealing  of 
the  two  openings  depending  on  the  form  of  the  ball;  for  example, 
where  the  bullet  is  solid  at  its  base,  the  outlet  heals  sooner  than 
the  entrance,  but  if  the  base  be  hollow,  then  the  exit  opening  does 
not  heal  earlier. 

After  osseous  fragments  and  other  foreign  matter  liave  been 
removed,  if  there  he  dependent  shreds,  these  should  be  excised ; 
and  then,  if  the  openings  are  large  enough  to  admit  them,  drain- 
age tubes  should  be  placed  in  each  one,  and  retained  there  as  long 
as  liquid  excreta  escape.  This  work  being  done,  the  dressing- 
should  be  completed  in  the  same  manner  as  in  the  case  of  the 
wound  with  a  single  opening. 

Though  the  lesion  just  described  is  greater  than  that  of  the 
blind  canal,  yet  the  fact  that  the  missile  has  escaped  from  the 
head,  and  probably  left  but  little  foreign  material  in  its  track,  are 
auspices  more  favorable  for  early  and  entire  recovery  than  exist 
in  the  case  of  the  blind  canal;  and  especially,  if  the  ball  in  the 
latter  has  not  been  discovered  and  removed;  for  such  lodged  ball 
may,  at  any  time,  obey  the  law  of  gravity,  and,  sinking,  encroach 
on  the  vital  nuclei  in  the  lower  part  of  the  encephalon. 

Trepanation. — In  the  treatment  of  injuries  of  the  cranium,  an 
important  operation  has  been  reserved  for  a  sjoecial  chapter;  this 
is  the  use  of  an  instrument  by  which  the  cranial  wall  is  opened. 
This  operation  was  denoted  anciently  by  the  term  trepanation, 
and  the  instrument  for  doing  it  was  named  a  trepan,  which  was 
worked  after  the  fashion  of  a  carpenter's  bit  or  wimble.  The 
more  modern  name  for  the  operation  is  trephination,  so  called 
from  the  trephine,  with  which  the  work  is  done;  the  trephine 
resembles  an  auger  or  gimlet,  and  is  worked  similar  to  that  im- 
plement. The  work  done  by  both  the  trepan  and  trephine  is 
effected  by  a  circular  saw,  in  the  form  of  a  corona  or  crown,  which 
on  one  end  is  armed  with  teeth.  These  instruments  are  only 
moditications  of  an  instrument  which  was  in  common  use  in  the 
earliest  recorded  period  of  antiquity.  The  wars  of  olden  times, 
as  well  as  of  more  recent  ones,  furnished  ample  material  in  inju- 
ries of  the  head.  Cases  of  compression  of  the  brain  from  depres- 
sion of  a  portion  of  the  containing  w^all  must  frequently  have 
occurred,  and  it  is  probable  that  the  observation  was  early  made 
that  the  uplifting  of  such  depressed  bone  was  followed  by  relief 
of  the  injured  one;  and  hence  the  recourse  to  some  instrument  by 


ISG  CRANIUM. 

wliich  the  elevation  could   be  done;  thence  the  early  origin  of 
such  boring  and  elevating  instruments. 

In  liis  admirable  work  concerning  injuries  of  the  head,  after 
Hippocrates  has  described  five  species  of  cranial  lesion,  he 
remarks  that  ''among  these  modes  of  lesion,  those  to  which  the 
trepan  must  be  applied  are  a  contusion  which  is  visible  or  invis- 
ible, and  a  fracture  that  is  visible  or  invisible."  And  then  follows 
the  mention  of  a  form  of  wound,  in  Greek  named  "hcdra,^'  which 
has  so  puzzled  the  Hellenists  tliat  Littr^,  the  most  famous 
translator  of  Hip[)0crates,  instead  of  defining  it,  has  retained  the 
original  word, in  his  French  version.  The  word  evidently  meant 
a  wound, or  the  site  of  a  wouml.  Continuing  then  the  language  of 
Hippocrates,  the  following  occurs:  "  Besides,  if  a  v;oviiu\{Jiedra)  has 
been  made  in  the  bone  by  a  missile,  and  there  is  a  fracture  and 
contusion,  or  a  contusion  without  fracture,  the  case  demands  the 
trepan.  But  when  tlie  bone  has  been  displaced  from  its  natural 
position  and  is  depressed,  then  it  is  seldom  that  the  trepan  is 
needed;  the  more  the  bone  is  depressed  and  broken,  the  less  ireed 
there  is  of  trepanning.  The  wound  {hedra)  without  fracture  and 
contusion,  does  not  require  this  operation."  These  words,  which 
are  the  first  existing  lines  in  tlie  long  chapter  since  written  on 
the  subject  of  trephination,  are  remarkable  as  prophetically  con- 
curring with  subsequent  experience.  It  is  clear  from  the  reference 
to  trepan,  without  describing  the  instrument,  that  the  latter  was 
well  known  and  in  common  use.  Hippocrates,  afterwards,  often 
refers  to  the  operation,  and  carefully  describes  the  cases  in  which 
it  should  be  employed.  "It  should  not  be  done  on  a  suture,  but 
to  one  side  of  it."  The  danger  of  injuring  the  meninges  is  spoken 
of,  and  the  caution  given  not  to  expose  these  too  much.  Also,  in 
the  infant,  the  thinness  of  the  wall  is  mentioned,  and  on  that 
account  the  work  should  be  done  with  unusual  care;  and  in 
some  cases  it  suffices  to  merely  open  with  a  very  small  trepan. 
In  the  work  of  using  the  instrument,  Hippocrates  advises  to 
proceed  with  the  section  slowh^  wlien  the  bone  is  nearly  sawn 
through,  so  that  the  parts  within  the  head  may  not  be  injured. 
He  coun.sels  also  to  frequently  withdraw  the  instrument  and 
plunge  it  in  cold  water,  to  cool  it;  for  without  this  precaution,  the 
bone  may  be  burned  and  caused  to  die.  He  tells  how  the  work 
should  be  done  differently  in  different  morbid  conditions  of  the 
bone;  for  example,  if  tlie  bone  be  suppurating,  there  is  danger  of 
sawing  too  rapidly.  He  likewise  used  as  aid  and  precursor  of  the 
trepan  the  rugina  or  rasp,  in  all  cases  in  which  the  injury  of  the 


TREPANATION.  187 

bone  was  not  apparent;  in  such  the  surface  of  the  bone  was  to  be 
rasped  away,  and  the  deeper  osseous  strata  were  to  be  tested  within 
and.,  if  signs  of  deeper  injury  be  revealed,  then  the  trepan  must 
be  resorted  to. 

Enough  has  been  cited  to  prove  the  popularity  of  the  trephine 
the  Hippocratic  era  of  surgery.  This  popularity  continued  and  is 
mentioned  and  mildly  censured  by  Celsus,  who  says  that  in  every 
injury  of  the  cranial  bones,  the  ancients  proceeded  at  once  to 
instruments,  by  which  the  bone  was  excised.  Instead  of  this 
treatment,  the  more  conservative  Roman  would  first  try  local 
remedies:  "but  if  these  fail  and  fever  appear  early  after  the 
wound,  and  sleep  be  short  and  disturbed  by  tumultuous  dreams, 
and  the  wound  remain  open  and  moist,  and  glands  swell  in  the 
neck,  and  there  be  likewise  a  distaste  for  food,  then  one  must 
resort  to  the  scalpel  and  the  trephine."  In  the  work  of  trephin- 
ing, Celsus  directed  that  it  be  done  by  one,  two  or  three  borings, 
as  the  case  may  demand,  and  thus  the  bone  lying  between  the 
bored  orifices,  may  be  removed.  The  opinion  and  practice  of 
Hippocrates,  however,  maintained  ascendency  for  many  genera- 
tions; and  it  is  also  probable  that  this  practice  prevailed  for  many 
centuries  before  Hippocrates,  for  his  work  on  injuries  of  the 
head  affords  ample  evidence  that  surgery  in  certain  directions 
was  well  advanced,  though  there  remain  no  records  of  it.  The 
sanctity  which  attaches  to  the  past,  and  that  hesitates  to  abandon 
lines  of  action  which  are  evidently  erroneous,  had  its  share  in 
maintaining  the  use  of  the  trepan  in  the  middle  ages,  and  trans- 
mitting it  as  an  enlarged  legacy  to  modern  times.  The  fortune 
of  trephining  has  been  more  lucky  than  that  of  the  ligation  of 
vessels;  the  latter,  though  one  of  the  most  frequent  needs  to  the 
wounded  man,  stranded  in  the  current  of  time  for  a  thousand 
years,  while  that  of  the  trephine  survived  and  attained  a  larger 
sphere  of  action,  with  advancing  time;  the  ligature  was  lost  in 
the  morass  of  scholastic  inertia  in  which  human  science  lay 
grounded  for  so  many  ages;  the  trepan,  meantime,  appears  never 
to  have  fallen  into  disuse.  During  the  eighteenth  century  and 
the  first  quarter  of  the  present  one,  the  trephine  rose  to  a  degree 
of  favor  unknown  in  antiquity.  In  fact,  the  operation  became 
a  fashion,  and  did  its  work,  like  the  lancet,  whether  right  or  wrong, 
without  rebuke  or  censure.  The  absolute  recklessness  with  which 
this  operation  was  done,  and  the  instances  in  which  a  large  por- 
tion of  the  cranial  vault  was  removed,  justifies  the  satirical 
remark  of  Sir  A.  Cooper,  that  "it  is  remarkable  how  much  surgery 


188  CJtAXlLM. 

it  takes  to  kill  a  man."  Survival  after sucli  multii)lc  trepliiiiation 
as  one  finds  in  the  records  of  olden  surgery,  certainly  demonstrates 
that  the  operation  is  rarely  a  fatal  one. 

Among  surgeons  of  modern,  or  comparatively  modern  times, 
who  have  strongly  advocated  the  trephine,  are  Petit,  Pott,  Sabatier 
and  Louvrier,  These  urge  that  the  operation  should  be  done  as  a 
preventive  measure;  that  by  the  timely  use  of  the  trephine,  in 
case  of  injury  of  the  cranial  wall,  inflammatory  action  and  other 
accidents  consequent  on  the  fracture  can  be  forestalled,  and  thus 
prevented,  or  diminished.  On  the  other  hand,  as  strong  opponents 
of  the  operation,  may  be  mentioned  Sir  A.  Cooper,  Brodie,  Aber- 
nethy,  Desault,  Langenbeck  and  Malgaigne.  Alalgaigne  was  per- 
haps the  most  determined  opponent  of  trephining  among  modern 
surgeons,  and,  by  his  writings,  he  tended  to  check  the  abuse, 
and  perhaps  the  legitimate  use  of  the  trejihine.  Thus  in  words 
often  quoted  he  says:  "In  my  conviction  most  deeply  grounded, 
all  the  doctrine  concerning  the  compression  of  the  brain  from 
wounds  of  the  head,  in  which  it  is  claimed  that  trephining  is 
demanded,  seems  to  me  to  be  a  long  and  deplorable  error,  and 
which  even  in  our  time  is  still  pursuing  its  victims."  This 
denunciatory  criticism  was  evoked  by  the  illimitable  use,  or 
rather  abuse,  of  the  instrument.  Thus  it  is  recorded  that  Stalpart 
van  der  Weil  trephined  one  patient  twenty-seven  times;  the 
Prince  of  Orange  had  seven  openings  made  in  his  skull  by  the 
trephine;  and  Fergusson  tells  the  story  of  a  surgeon,  who,  to 
remove  extravasated  blood  from  the  cranial  cavity,  continued  to 
use  the  instrument  until  he  was  told  by  the  surrounding  spec- 
tators that  the  patient  had  been  dead  for  some  time. 

More  exact  knowledge  of  the  relations  of  the  brain  and  the 
cerebro-spinal  fluid  makes  it  evident  that  cerebral  compression 
can,  to  a  considerable  extent,  be  compensated  b}'  the  outflow  of 
that  fluid.  And  also,  the  observation  has  often  been  made  that, 
after  very  extensive  depression  or  driving  inwards  of  the  cranial 
wall,  the  abnormal  condition  did  not  cause  cerebral  trouble;  or, 
if  such  was  present,  the  sunken  wall  was  soon  tolerated,  and  no 
subsequent  trouble  w^as  experienced  from  it.  To  this  the  writer 
would  answer  that  it  is  true  that  the  forces  of  life  have  great  tol- 
erance, and  often  endure  what  they  cannot  escape  from,  yet  it  is 
probable  that,  had  their  mute  patience  the  power  of  language, 
submission  would  often  be  accompanied  by  remonstrance.  It  is 
certainly  the  duty  of  surgical  art  to  rem.ove  the  necessity  of  such 
tolerance,  and  to  so  clear  the  pathway  that  the  forces  of  life  can 
move  without  clog  or  fetter. 


TREPANATION.  189 

In  a  review  of  surgical  literature  from  1840  to  1850,  one  finds 
that  the  advocates  and  op]3onents  of  trephination  waged  an  indus- 
trious controversy,  and,  as  a  partisan  of  the  o^oeration,  Spatli  in 
1844  decried  the  prevalent  fashion  of  denouncing  it.  He  claims 
that  many  cases  of  cranial  injury  demand  it,  and  formulates,  as  a 
rule  for  guidance,  that  in  all  cases  in  which  the  functions  of  the 
brain  are  interfered  with,  through  irritation  or  pressure  due  to  a 
wound,  one  must  trephine.  Spath  refers  to  the  experience  of  E. 
Walther,  who,  in  one  hundred  and  thirty-three  cases  of  trephin- 
ing, lost  but  thirteen  patients,  while  in  a  series  of  twenty-seven 
cases  not  trephined,  which  vfere  similar  in  character  to  those 
which  were  trephined,  thirteen  died.  The  teachings  of  Textor,  a 
German,  discouraged  trephining,  while  Cock,  a  surgeon  of  London, 
was  favorable  to  trephining,  especially  in  cases  of  suspected 
rupture  of  the  middle  meningeal  artery;  and,  according  to  Cock, 
the  evidences  of  such  rupture  are  deep  coma,  stertor,  puffing 
respiration,  absence  of  muscular  movement  in  the  face,  and 
death-like  immobility  of  the  limbs;  trephining  should  be  done 
when  such  symptoms  are  present. 

In  a  discussion  upon  trephining  in  the  Society  of  Surgery  in 
Paris,  1867,  it  was  shown  that  the  violent  oj)position  of  Malgaigne 
to  the  procedure  had  nearly  remanded  it  to  disuse  in  France; 
Le  Fort  found  that,  from  1857  to  1866,  but  three  reports  of  tre- 
phining were  recorded  in  the  journals.  In  England,  however  the 
operation  remained  in  use,  as  hitherto;  and  there  were  reported 
in  that  time  one  hundred  and  thirty-five  cases,  of  which  fifty 
recovered,  giving  a  mortality  similar  to  that  which  occurred  after 
one  hundred  and  seven  operations  done  by  surgeons  in  the 
American  war. 

The  eminent  English  authority,  James  Paget,  1870,  laid  down 
the  following  indications  for  trephining:  "In  simple  fracture  in 
which  the  scalp  is  unopened,  and  there  is  no  depression  of  the 
skull,  nor  symptoms  of  comj^ression  of  the  brain,  then  trephining 
should  not  be  done.  But  if  signs  of  compression  be  present,  and 
still  there  is  no  cranial  depression,  in  such  cases  trephine,  if  the 
site  of  fracture  can  be  located.  When  there  is  depression  of  bone, 
and  there  are  signs  of  compression,  if  the  subject  be  a  young  one, 
do  not  trephine;  and  if  the  subject  be  old,  even  then  the  propri- 
ety of  trephining  is  doubtful."  But  an  invariable  rule  laid  down 
by  Paget  is  that  "though  the  scalp  be  unbroken,  and  yet  the  skull 
is  depressed,  and  symptoms  of  compression  are  present,  then  tre- 
phining should  be  done.     Again,  where  the  scalp  is  opened,  and 


190  CRANIUM. 

there  is  no  cranial  depression,  nor  symptom  of  compression,  then 
do  not  trephine.  But  if  the  bone  is  not  depressed,  and  yet  there 
be  present  signs  of  compression,  then  one  should  trephine.  In 
the  young  where  the  bone  is  depressed  and  no  compression  exists 
then  do  not  trephine,  but  in  such  cases  in  the  old  it  is  proper  to 
trephine.  In  cases  in  which  the  scalp  is  opened,  and  compression 
and  depression  both  exist,  then  tre})hine." 

The  above  rules  seem  correct  guides,  yet,  as  Hueter  remarks, 
"Pao-et  should  have  defined  more  accurately  what  he  implies  by 
compression." 

Antiseptic  surgery,  here  as  elsewhere,  has  emboldened  the  sur- 
geon to  venture  further  in  operative  work.  Leser,  of  Halle, in 
1885  reported  a  series  of  thirty-six  trephinations  with  four 
deaths;  in  the  fatal  cases,  the  injury  was  very  severe.  He  used 
drainage  tubes,  which  were  brought  in  contact  with  the  cerebral 
substance,  and  the  patients  soon  were  permitted  to  walk  around. 

For  many  years  the  doctrine  iield  sway  that  tlie  cerebrum 
was  insensible  to  irritants,  whether  meclianical,  thermal  or  elec- 
trical in  nature.  In  1800  the  writer  was  a  witness  to  experiments 
made  by  Flourens,  in  Paris,  by  which  this  doctrine  seemed  most 
certainly  established.  In  terms  of  undisguised  arrogance  and 
vehement  pomp,  tlie  famous  Secretary  of  the  Institute  enunciated 
these  doctrines  with  the  strongest  conviction  that  they  were  des- 
tined to  remain  as  immutable  truths.  Less  than  twenty  years- 
elapsed  when  this  doctrine  was  proved  erroneous  by  the 
researches  of  Fritsch  and  Hitzig,  in  which  they  discovered  that 
the  COTtex  of  the  cerebrum  is,  at  certain  points,  sensitive,  and  will 
respond  to  an  electrical  irritant.  These  discoveries  probably  had 
a  germinal  suggestion  in  the  researches  of  Broca,  who  had  found 
that  articulate  speecli  has  its  site  of  innervation  in  a  frontal  con- 
volution of  the  brain.  The  discoveries  of  Fritsch  and  Hitzig, 
that  centers  of  innervation  for  movement  of  the  leg  and  arm  are 
located  in  the  cortex  beneath  the  parietal  bone,  were  soon  after- 
wards verified  in  France  and  England.  In  France,  the  subject 
was  studied  by  Vulpian;  his  experiments  were  witnessed  by  the 
writer, in  1876.  In  England,  controlling  verification  was  furnished 
by  Ferrier,  who  experimented  on  monkeys;  and  from  the  simi- 
larity between  the  simian  and  human  brain,  the  deduction  was 
permissible  that  similar  centers  existed  in  the  brain  of  man.  In 
the  pathological  field,  the  diligent  hand  of  Charcot  soon  collected 
a  number  of  facts,  which  clearly  demonstrated  that  there  are 
localized  functional  centers  on  the  surface  of  the  cerebrum.     And 


TREPHIXATION.  191 

soon  the  doctrine  was  corroborated  and  confirmed  by  many 
observers,  that  there  are  definite  and  determinable  foci  on  the 
cerebral  cortex  of  innervation  of  the  organs  of  motion  and  of 
special  sensation.  This  discovery  is  the  offspring  of  vivisection 
so  much  decried  by  the  half-educated  sentimentalist,  whose  very 
existence  has,  probably,  been  permitted  by  the  work  which  he 
decries.  The  discovery  of  cerebral  functional  localization  is  one 
of  the  most  important  of  the  nineteenth  century;  it  has  brought 
more  light  to  the  cerebral  clinician ;  it  has  added  a  new  jewel  to 
the  crown  of  the  trephine;  and  this  instrument,  whicli  lias  had 
so  cliangeable  a  fortune  in  banisliment  and  recall,  will  not  be 
wrested  again  from  the  surgeon's  hand. 

Though  a  number  of  centres  of  innervation  have  been  defi- 
nitely located,  yet  those  which  specially  concern  the  operative 
surgeon,  are  those  for  the  npper  and  lower  extremities,  and  that 
of  Broca's  lingual  convolution;  especially  the  former  two. 

The  location  of  the  centres  for  the  limbs,  according  to  Charcot 
and  Lucas  Championniere,  is  in  a  zone  comprising  the  superior 
two-thirds  of  the  ascending  frontal  and  parietal  convolutions,  and 
is  contiguous  to  the  fissure  of  Rolando.  And  these  motor  centres 
are  beneath  the  anterior  half  of  the  pai'ietal  bone,  in  a  space 
which  is  a  little  over  three  inches  in  height  and  sonaewhat  more 
than  one  inch  in  breadth. 

Since  these  central  points  are  adjacent  to  the  fisAire  of  Rolando, 
the  following  is  the  rule  of  Championiere  to  locate  this  line: 
First  find  the  site  of  the  anterior  fontanel,  by  causing  the  subject 
to  look  straight  forwards;  then  draw  a  line  from,  one  a\jditory 
meatus  to  the  other,  and  the  summit  of  the  curved  line  will  cor- 
respond to  the  fontanel.  Next  draw  a  line  from  the  fontanel 
backwards,  two  and  a  quarter  inches;  then  draw  from  the  external 
angular  process  of  the  orbit,  horizontally  backwards,  a  line 
nearly  three  inches  long;  now,  from  the  posterior  end  of  this 
line,  draw  a  line  perpendicularly  upwards  one  inch  and  a 
quarter;  between  the  upper  end  of  this  vertical  line  and  the 
posterior  end  of  the  first  line,  lies  the  fissure  of  Rolando.  Though 
this  admeasurement  will  prove  correct  for  many  crania,  yet 
for  some  it  will  vary  from  accuracy ;  for  in  the  brachycephalic, 
or  broad  head,  and  tlie  dolichocephalic,  or  long  head,  the  dis- 
tance between  the  points  above  given  cannot  conform  to  any 
fixed  standard.  In  such  cases  of  abnormal  cranial  form,  to  open 
the  wall  over  the  motor  centres,  the  trephine  should  be  used  in 
front  of  the  parietal  eminence,  within  a  vertical  zone  two  inches 


192 


CKANIUM, 


broad,  just  anterior  to  that  eminence.  And  tiiis  work  sliould  be 
done  on  the  side  oi)i)Ositeto  that  of  tliealTeeted  limbs.  Tlie  (hira 
mater  must  be  opened,  and  the  causal  agency  removed,  whether 
this  be  a  clot  of  blood,  a  collection  of  pu.s,  or  a  neoplasm.  If  the 
treidiining  be  done  for  the  relief  of  apha.sia,  then  the  operator 
must  seek  the  third  frontal  convolution  by  an  opening  lower  and 
more  anterior  than  that  which  is  made  to  find  the  motor  centre 
of  the  limbs.  Should  the  point  sought  for  not  l)e  discovered 
within  the  vertical  zone  mentioned,  another  opening  may  be  made 
above  or  below  the  first  one. 


''por(^i  kohe 


Occip 


FiGiRE  1.  Prepared  under  the  directions  of  the  author,  in  wliich  the  cere- 
bral convolutions  are  designated,  and  the  lingual  and  visual  centres,  and  those 
of  the  upper  and  lower  extremities,  are  indicated. 

The  injury  of  the  brain  reveals  itself  in  two  classes  of  subjective 
symptoms  the  opposite  of  each  other,  viz.,  those  of  excitation  and 
those  of  depression;  or  those  in  which  excitation  in  one  direction 
and  depression  in  another  are  present  in  the  same  case.  The 
indications  for  trephining  may  be  present,  arising  from  tlie.se 
opposite  conditions. 

As  has  been  shown,  the  operation  of  trephining  has  been  the 
subject  of  changing  vicissitudes;  an  analysis  of  its  history  shows 
that  it  has  been  resorted  to,  at  different  periods,  for  three  pur- 
poses: as  an  exploratory  and  diagnostic  aid;  as  prophylactic  or  a 


TEEPHIXATIOX.  193 

means  of  preveniing  the  development  of  trouble  in  the  head;  and 
lastly,  the  trephine  has  been  used  as  a  curative  agent. 

As  a  means  of  determining  the  extent  of  a  cranial  injur}-,  and 
especially,  to  determine  the  existence  of  fracture  and  possible 
detachment  of  the  inner  plate  of  the  skull,  trephining  was  recom- 
mended by  Sddillot  and  a  few  others.  And,  with  the  object  of 
discovering  a  suspected  clot  of  blood,  Sedillot  would  use  the  tre- 
phine; thus,  as  a  mere  aid  in  diagnosis,  and  to  enable  the  eye  to 
look  through  the  cranial  wall,  tlie  operation  has  been  advocated; 
and  if  one  opening  did  not  reveal  the  concealed  trouble,  then  the 
partisans  of  exploratory  trephination  would  pursue  their  work, 
in  fact,  continue  the  boring  until  the  object  of  search  was  discov- 
ered. The  most  remarkable  instance  in  which  this  adventurous 
work  was  pursued  to  the  utmost  limits  of  possibility  is  that  of 
Chabdon,  which  from  the  frecjuency  of  quotation  has  evidently 
won  in  surgical  history  the  prize  of  frequent  mention.  Chabdon 
applied  twenty-seven  crowns  of  the  trephine  to  the  skull  of  his 
patient,  and  had  the  rare  fortune  to  find  the  clot  of  extravasated 
blood,  and,  it  is  said,  saved  his  patient.  A  pupil  of  Sedillot,  who 
resorted  to  this  multifile  trephination,  was  less  fortunate;  his 
patient  died.  The  innocuity  of  trephination  has  its  limits;  and, 
though  trephining  is  now  done  with  fair  immunity  from  danger, 
yet  the  operation  is  not  to  be  done  for  the  purpose  of  merely  per- 
mitting intracranial  insight;  for  the  knowledge  thus  obtained 
might  be  drawn  more  safely  from  the  subjective  and  objective 
symptoms  of  the  patient. 

Trephining  was  used  as  a  preventive  measure  by  Hippocrates; 
in  fact,  it  is  probable  that,  inspired  by  his  teaching,  the  use  of  the 
instrument  was  oftener  invoked  by  the  old  surgeons  as  a  means 
of  prevention  than  as  a  means  of  cure.  Among  the  modern 
English  surgeons.  Pott  w^as  an  enthusiastic  ad  /ocate  of  prophy- 
lactic trephination,  and  somewhat  later,  Sddillot  among  the 
French,  besides  using  it  as  a  means  of  diagnosis,  employed  it  also 
as  a  preventive  measure.  The  cases  in  which  the  author  would 
use  it  preventively  are  the  following:  in  all  cases  of  stellate  or 
lineal  fracture  in  which  there  is  depression,  or  thrusting  inwards, 
of  a  portion  of  the  wall;  also  w4iere  a  foreign  body  has  entered, 
and  tlie  entrance-opening  is  not  large  enough  to  permit  the 
extraction  of  the  body,  or  the  removal  of  fragments  of  bone 
forced  inwards.  In  the  case  of  depression,  through  the  uplifting 
permitted  by  the  opening  made,  the  existing  symptoms  of  com- 
pression, sometimes  present,  will  be  relieved,  and  those  of  irrita- 


194  CRAXIUM. 

tion  destined  to  occur,  will  be  anticipated,  and  probably  prevented. 
Thus  the  wound  will  be  at  once  placed  in  conditions  so  favorable 
for  recovery  that  inflammation  and  suppuration  will  be  avoided, 
or  retained  in  safe  limits.  The  objection  urged  in  the  case  of 
fracture  with  depression,  that  the  trepliine  will  add  another 
wound,  is  not  valid,  since  the  work  done  by  means  of  the  opening 
made  allows  the  surgeon  to  substitute  a  much  less  perilous  wound 
for  the  one  that  previously  existed.  The  enlargement  of  an  open- 
ing as  aid  in  tlie  extraction  of  a  penetrated  missile  or  foreign 
body,  is  a  prophylactic  measure  sanctioned  by  all  surgeons.  But 
there  is  more  hesitation  concerning  the  propriety  of  the  ojieration 
in  cases  of  simple  fracture  without  depression.  To  open  the 
skull  at  once  in  this  case,  with  the  thoughts  of  encountering 
something  which  might  be  removed,  would  amount  to  mischiev- 
ious  meddling,  and  justify  the  sarcastic  rebuke  of  Stromeyer,  that 
"he  who  would  trephine  such  a  cranial  crack  must  have  a  crack 
in  his  own  head." 

This  early  use  of  the  trephine  fails  to  receive  support,  in  fact, 
is  condemned  by  the  results  of  statisticians  who  have  studied  the 
operation  in  long  series  of  cases.  For  example,  Bluhm,  in  1S70, 
collected  923  cases  of  trephination;  when  done  primarily  the 
mortality  was  55.26  percent;  when  done  secondarily,  the  mor- 
tality was  39.24  per  cent;  and  when  done  at  a  late  period,  the 
mortality  was  40  per  cent.  These  figures  favor  postjoonement  of 
the  operation. 

If  general  objection  has  been  urged  against  trephining  as  a 
diagnostic  procedure,  and  opinion  has  varied  in  regard  to  operat- 
ing as  a  preventive  means,  on  the  contrary,  respecting  trephin- 
ing as  a  curative  means  in  selected  cases,  opinion  is  not  discord- 
ant. From  adventurous  exploration  the  hand  had  better  be 
stayed,  and  in  the  field  of  expectant  prevention  hesitation  should 
have  a  frequent  place;  but  in  a  third  class  of  cases,  the  demand 
for  action  is  urgently  imperative  as  a  means  of  cure. 

In  the  injuries  of  the  head,  there  are  those  in  which  instru- 
mental interference  is  demanded  at  once,  or  within  a  brief  period 
after  the  accident;  and  in  such  cases,  there  may  be  an  opening 
through  the  scalp,  which  exposes  to  view  the  entire  extent  of  the 
injury;  for  example,  there  maybe  depression,  fragments  detached 
and  driven  inwards,  and  accompanied  by  a  foreign  body.  Or, 
without  an  opening  through  the  scalp,  symptoms  of  irritation  or 
depression  may  point  to  concealed  injury.  In  the  former  case, 
the  indications  as  to  what  is  to  be  done,  are  apparent;  the  open- 


TREPHIXATIOX.  195 

ing,  if  too  small,  is  to  be  so  enlarged  that  it  will  permit  of  the 
removal  of  fragments,  or  a  missile,  or  other  disturbing  agent. 
But  if  the  scalp  be  intact,  and  symptoms  of  grave  intra-cranial 
disturbance  be  present,  then  the  integument  should  be  opened 
and  the  wall  explored.  If  the  wall  be  found  intact,  then  the 
surgeon's  action  must  be  shapen  entirely  by  the  subjective  symp- 
toms. If  there  should  be  present  the  phenomena  of  concussion, 
in  which  the  patient  is  in  a  state  of  coma,  with  normal  respira- 
tion and  the  muscles  relaxed,  then  immediate  trephining  would 
be  ill-timed;  it  would  be  better  to  w.ait  until  the  patient  rallies 
from  the  concussion.  It  should  be  remarked  that  coma  here  is 
not  deemed  by  all  surgeons  a  contra-indication  to  trephining;  the 
more  prudent,  however,  counsel  delay. 

But  when  in  the  commencement  there  exist  symptoms  of 
compression  in  which  the  subjective  phenomena  are  of  the  type 
of  depression  in  the  form  of  monoplegia  or  more  general  motor 
palsy,  with  or  without  partial  convulsions  concurring  with  coma, 
and  without  or  with  a  wound  of  the  scalp,  then  it  is  proper  to 
trephine.  Le  Fort,  a  strong  friend  of  the  trephine,  has  formulated 
the  axiom  :   "When  in  doubt,  one  should  act." 

When  the  injury  is  such  as  to  indicate  the  lesion  of  an  intra- 
cranial artery,  and  the  symptoms,  whether  of  exaltation  or  depres- 
sion, point  to  the  effusion  of  blood  from  the  ruptured  vessel,  then 
the  immediate  use  of  the  trephine  is  explicitly  indicated;  if  done 
at  once,  an  opportunity  will  be  afforded  of  removing  tlie  clot 
already  formed,  and  to  secure  the  vessel,  so  that  further  bleeding 
will  be  prevented. 

Velpeau  urgently  advises  the  use  of  the  trephine  in  cases  in 
which  blood  has  been  effused  between  the  dura  mater  and  the 
cranium;  for  in  such  patients  the  blood  continues  to  escape,  and 
to  push  the  dura  mater  more  and  more  against  the  brain;  and 
then  the  subject  is  menaced  with  inflammation  of  the  brain, 
effusion  into  the  arachnoid  cavity,  and  softening  of  the  cerebral 
structure;  in  such  a  patient  symptoms  of  compression  will  soon 
appear,  which  will  justify,  in  fact  demand,  early  trephining. 
This  intra-cranial  effusion  of  blood  is  caused  by  rupture  of  the 
greater  and  lesser  meningeal  arteries,  especially  of  the  larger  one. 
And  in  case  the  injury  is  at  the  base  near  the  entrance  of  the 
arteries  into  the  skull,  then  the  blood  will  be  poured  out  within 
the  dura  mater;  but  if  the  injury  is  higher  up,  then  the  effusion 
occurs  exterior  to  the  dura  mater,  and  the  latter  membrane  will 
then  be  detached  on  a  small  or  larg-e  scale  from  the  cranium. 


106  cRAXirM. 

Sucli  detachment  is  less  in  the  infont  than  in  the  aduh,  owing  to 
the  firmer  connection  of  tlie  membrane  to  the  bone,  in  the  infant. 
In  the  adult,  Marchant  has  found  that  the  separation  can  occur 
from  tlie  lesser  wings  of  the  sphenoid  to  within  nearly  one  inch 
of  the  internal  occipital  protuberance;  and  it  may  reach  to  the 
falx  major  cerebri  above,  and  downwards  to  a  horizontal  line 
which  begins  at  the  apophyses  of  Ingrassias  and  runs  thence 
backwards — no  small  space  to  extract  clotted  blood  from,  as  the 
author  once  verified.  The  higher  up  in  the  cranial  wall  the 
injury  is  situated,  the  smaller  the  vessel  will  be,  and  the  less  will 
be  the  amount  of  blood  effused. 

Kronlein,  a  German,  in  1SS6,  published  his  observations  and 
studies  of  lesion  of  the  middle  meningeal  artery;  he  finds  the 
haemorrhage  may  be  limited  to  a  small  spot,  or  it  maybe  diffused. 
When  the  clot  is  isolated,  its  site  may  be  temporo-parietal,  lying 
in  the  middle  cranial  fossa,  or  the  clot  may  lie  beneath  the  parie- 
tal tuberosity,  which  Kronlein  designates  the  parieto-occipital 
site.  A  third  location  is  the  fronto-temporal,  in  which  the  blood 
lies  under  tlie  frontal  protuberance.  The  clot  in  most  of  these 
situations  can  be  reached  by  trephining  through  the  anterior 
inferior  angle  of  the  parietal  bone;  through  this  oj>ening,  the 
diffused  clot,  as  well  as  that  in  the  temporo-parietal  and  fronto- 
parietal sites,  can  be  reached.  And  if  no  clot  be  found  in  either 
of  these  sites,  then  an  opening  must  be  made  beneath  tlie  parie- 
tal eminence,  and  through  this  a  clot  in  the  parieto-occipital 
situation  can  be  reached. 

In  the  cases  cited,  trephining  done  curatively  is  performed 
immediately;  in  another  small  class  of  cases,  the  work  may  be 
done  late,  or  after  the  lapse  of  some  days  or  weeks.  For  example, 
if,  after  some  time,  symptoms  of  irritation  or  depression  present 
themselves,  the  operation  may  be  done  as  a  means  of  relief  It  is 
confessed  by  all  the  advocates  of  trephining  here,  that  it  is  diffi- 
cult to  distinguish  the  phenomena  of  encephalitis  from  those 
which  proceed  from  a  local  irritant  which  could  be  removed  by 
opening  the  cranium.  The  most  enthusiastic  [)artisans  would  do 
the  operation  in  ence})halitis  of  traumatic  origin,  with  the  hope 
that  the  cause  might  be  discovered  and  removed"  by  trephining. 
As  such  cases  almost  always  terminate  fatally,  the  effort  to  avert 
such  an  end  is  commendable,  even  tliough  it  should  not  be 
crowned  with  success;  for  by  such  a  course  the  patient  suffers 
no  loss;  his  friends  are  consoled  with  the  view  that  something  is 
being  done  for  his  rescue;  and  the  surgeon  has  afterwards  the 


TREPHINATION.  .         197 

satisfying  reflection  that  lie  did  not  stand  supinely  by,  and  let 
his  patient  die. 

And,  lastly,  the  trephine  may  be  used  at  a  still  more  remote 
period  than  the  one  mentioned.  For  example,  there  ma}^  arise, 
months  after  the  receipt  of  the  injury,  trouble  of  an  irritated  or 
exalted  character,  such  as  convulsions  and  epileptic  attacks.  Or 
the  supervening  affection  may  be  of  the  adynamic  or  depressed 
type,  such  as  some  form  of  palsy,  aphasia,  or  some  disturbance  of 
the  functions  of  motion  and  sensation.  Such  trouble  may  arise 
from  a  collection  of  pus,  a  clot  of  blood,  a  fragment  of  bone  or  a 
foreign  body.  The  scar  of  a  healed  wound  can  cause  similar 
morbid  conditions.  In  such  cases  the  trephine  opens  a  way 
through  which  the  central  causal  agency  can  be  reached  and 
removed.  By  this  means  it  may  be  possible  to  cure  or  improve 
the  patient's  condition  by  extracting  a  missile,  excising  a  splinter- 
like process  of  bone,  excising  scar-like  tissues,  or  by  opening  a 
pus  cavity. 

This  instrument  has  been  invoked  as  a  not  infrequent  assist- 
ant in  the  cure  of  epilepsy.  It  has  been  found  that  tiiis  disease 
can  often  be  referred  to  some  traumatic  cause  of  the  skull,  to  some 
injury  in  which  tlie  cranial  wall  is  deformed,  and  presses  on  and 
alters  the  form  of  the  brain.  The  wound  of  the  skull  may  have 
been  slight,  so  insignificant  as  to  have  left  no  evidence  of  itself  on 
the  outside;  or  it  may  have  been  an  extensive  wound  in  which 
the  wall  has  been  broken  and  fragments  lost.  The  epilepsy  may 
appear  soon  after  the  injury,  yet,  commonly,  it  supervenes  at  a 
later  jjeriod.  This  is  especially  so  in  cases  of  the  open  breach,  in 
which  there  is  closure  by  cicatrization.  From  the  author's  obser- 
vation, it  is  in  the  young  subject  that  cranial  injury  most  usually 
becomes  the  exciting  cause  of  epilepsy;  in  the  child,  he  has 
seen  epilep.sy  originate  from  a  seemingly  insignificant  injury  of 
the  head,  in  which  there  was  merel}''  a  slight  depression  of  the 
bone  without  fracture.  The  site  of  the  injury  was  in  the  upper 
part  of  the  frontal  bone,  to  the  outside  of  and  above  the  right 
frontal  tuberosity.  The  epileptic  attacks  occurred  once  or  twice 
daily,  and  were  increasing  in  both  violence  and  frequency.  The 
removal  of  a  section  of  the  wall  from  the  part,  which  was  reported 
to  be  the  site  of  an  injury  from  a  fall,  cured  the  lad  of  his  epilep- 
tic disease.  The  bone  which  was  removed  showed  signs  of  thick- 
ening. After  the  removal  of  the  bone,  the  inner  plate  was 
removed  to  a  small  extent  from  the  bony  wall  around  the  orifice. 
This  work  was  so  done  with  chisel  and  forceps  as  to  remove  the 


198  CKANUM. 

sharp  edge  of  tlie  bone,  against  which  the  brain  rested  in  its 
slight  ascent  into  the  opening  made.  Besides  this  inner  beveling 
done  with  forceps,  similar  to  those  used  by  dentists  in  the  work  of 
dental  exsection,  there  was  excised  an  additional  portion  of  the 
wall,  which  was  found  to  be  thickened  similarly  to  that  portion 
removed  by  the  trephine.  The  remaining  breach  was  elliptical 
in  outline.  The  cure  was  a  permanent  one,  as  verified  by  subse- 
quent observation.  The  epilepsy  in  this  case  may  be  ascribed 
to  the  continued  irritation  to  wljich  the  brani  was  subjected  by 
the  slight  encroacliment  of  the  thickened  wall  upon  it.  As  the 
antithesis  in  injury  to  this  case  was  another  in  wliich  the  skull 
was  extensively  broken  over  the  motor  tract  of  the  cerebrum, 
and  fragments  of  the  bone  were  removed.  The  membranes  were 
torn  and  cerebral  matter  was  lost.  The  part  healed  with  exten- 
sive cicatrization,  contraction  and  inversion  of  the  surrounding 
bone  This  boy  recovered, and  for  some  time  wasin  perfect  health; 
but  after  a  few  years,  as  he  approached  puberty,  he  became  the 
subject  of  epilepsy.  The  osteophytic  growths  from  the  margin 
of  the  fractured  bone  evidently  became  the  spines  of  irritation 
which  caused  the  convulsions.  As  no  permission  was  granted 
for  trephining  in  this  case,  wliat  the  operation  might  have  done 
for  relief  remains  unknown.  In  a  third  case  the  man  was  at  the 
middle  of  life,  and  his  epilepsy  was  referable  to  an  injury  of  the 
.-kull  received  seven  years  before.  The  operation  was  done  by 
the  writer,  and  furnished  relief  for  a  few  months;  the  disease  then 
reappeared  in  violence,  and  at  intervals,  similar  to  the  former 
course  of  the  disease.  In  a  fourth  case,  a  young  man,  who  had 
often  been  injured  by  falling  from  a  horse,  became  the  subject  of 
frequently  recurring  attacks  of  epilepsy;  trephining  over  the  left 
motor  tract  with  ligation  of  the  left  carotid  artery  effected  a 
cure.  And  a  fifth  man,  the  subject  of  epilepsy  caused  by  a  blow 
without  fracture  of  the  left  parietal  bone,  was  cured  by  removing 
a  considerable  section  from  the  parietal  bone. 

In  the  three  cases  in  which  a  cure  w'as  effected,  the  trephined 
portions  of  bone  showed  merely  a  slight  thickening  of  the  cranial 
wall ;  there  were  no  signs  of  depression. 

In  1884,  Walsham,an  English  surgeon,  collected  statistics  in 
reference  to  the  results  of  trephination  done  for  the  cure  of  epi- 
lepsy; of  eighty-two  cases  in  which  it  was  done,  twenty  died  and 
forty-seven  were  relieved  or  cured;  he  concludes  that  these 
results  justify  trephining  in  such  cases. 

In  a  species  of  ejiilepsy,  in  which  but  one-half  of  the  body  is 


TRErillXATIOX.  199 

attacked  with  spasmodic  contractions,  trephination  has  been 
resorted  to  with  successful  result.  In  this  form  of  epileps}^ 
described  by  Hughlings  Jackson,  and  named  after  him  Jackso- 
nian,  the  disease  depends  on  an  affection  of  the  cortex  of  the  cere- 
bral motor  centre  on  the  opposite  side;  and  the  trephine  is 
employed  to  remove  a  portion  of  the  cranial  wall  overlying  the 
centre,  thus  permitting  the  removal  of  some  of  the  cortex,  by 
which  the  centre  is  reduced  to  subsequent  inactivity. 

In  cases  of  epilepsy  in  which  the  disease  could  be  traced  to 
neither  functional  nor  objective  cause,  trephining  has  been  done 
with  the  report  of  successful  event.  In  the  accidental  contingen- 
cies to  which  the  developing  head  is  exposed,  it  is  conceivable 
that  some  injury  in  these  cases  may  have  deformed  the  wall 
which  the  trejjhine  was  able  to  modify  to  the  benefit  of  the 
patient. 

Before  proceeding  to  the  use  of  the  trephine,  one  should  take 
into  account  the  anatomical  character  of  the  wall  which  is  to  be 
bored  through;  also  the  relation  of  the  wall  to  the  sinuses  or  chan- 
nels for  venous  blood,  which  lie  near  it. 

The  wall  in  different  persons,  as  has  been  mentioned,  is  of 
variable  thickness;  it  may  be  only  a  line  thick  in  cases  of  extreme 
thinness;  and  then  again,  it  may  be  a  half-inch  thick  ;  and  this 
can  only  be  discovered  as  the  work  of  boring  is  being  done. 
The  operator  must  also  consider  the  component  parts  of  the  wall, 
viz.,  the  external  and  internal  plates  and  the  intermediate  diploe. 
"When  the  wall  is  thin,  there  is  but  little  or  no  diploetic  structure; 
and,  as  vessels  exist  in  this  which  bleed  when  wounded,  the 
absence  of  blood  in  the  bone-dust  indicates  that  there  is  little  or 
no  diploe,  and,  consequently,  that  the  cranial  wall  is  thin.  The 
diploetic  vessels  are  largest  near  the  foramina,  which  partly  or 
completely  perforate  the  wall;  these  exist  normally  in  the  frontal, 
parietal  and  mastoid  regions.  The  bone-dust  from  the  saw- 
ing is  commonly  sufficient  to  arrest  the  bleeding  from  these 
vessels  when  wounded,  yet  they  may  reopen  and  the  escaping 
blood  may  cause  some  trouble.  A  subjacent  sinus  is  a  contra- 
indication to  using  the  trephine  directly  over  it;  for  instance, 
the  trephine  should  not  enter  over  the  superior  longitudinal 
sinus,  viz.,  in  that  region  corresponding  to  the  median  line  of  the 
cranial  vault,  extending  from  the  glabella  to  the  external  occipi- 
tal protuberance.  The  superior  longitudinal  sinus  lying  there 
increases  in  width  as  one  passes  backward ;  at  its  posterior  end  it 
is  nearly  a  half  inch  wide.     To  remove  the  bone  Iving  over  this. 


200  t-HANHM. 

it  is  better  to  trephine  on  each  side,  and  then  remove  with  forceps 
the  bridge  lying  between  the  openings.  And  should  it  be  needed 
to  trephine  beliind  the  ear,  as  is  sometimes  done  to  give  exit  to 
pus  developing  in  connection  with  the  auditory  apparatus,  then 
the  work  must  be  done  cautiously, so  as  to  avoid  the  lateral  sinus. 

One  would  proceed  with  the  greatest  safety  by  first  removing 
the  external  plate,  and  then  completing  the  work  with  the  curved 
chisel  or  gouge,  worked  without  mallet,  by  the  hand,  alone ;  and 
if  the  work  can  not  be  done  with  one  hand,  then  use  as  aid  the 
other  hand.  In  1847  this  plan  of  trephining  was  announced  by 
Roux,  wlio  named  it  the  method  of  trephining  by  evulsion. 
He  employed  it  to  avoid  the  vessels,  and  thinks  that  tlius  one 
might  open  safely  over  the  lateral  sinus,  as  well  as  the  other  sin- 
uses. Roux  says  that  one  can  also  open  into  the  cranial  cavity 
above  and  below  the  petrous  portion  of  the  temporal  bone,  and 
thus  enter  the  cavity  above  and  below  the  tentorium. 

The  ancients  in  trephining  carefully  avoided  the  sutures;  the 
counsel  of  Hippocrates  preserved  these  lines  intact  for  many  cen- 
turies after  his  time;  and  as  Hippocrates,  through  his  imperfect 
anatomical  knowledge,  placed  sutures  in  the  skull  where  they  do 
not  exist,  hence  the  field  of  trephination  had  extensive  limita- 
tions. Some  centuries  later,  Berenger  di  Carj)i  crossed  the  for- 
bidden sutural  line,  and,  finding  that  no  injury  followed,  the 
suture  has  since  been  disregarded  in  trephining. 

There  are  two  forms  of  the  instrument  used  for  trephining; 
and  these  have  doubtless  been  modeled  from  implements  to  be 
found  in  the  shops  of  the  smith  and  carpenter,  the  storehouses 
whence  have  been  drawn  the  most  of  the  instruments  used  in 
surgery.  The  one  form  of  instrument  is  that  W'hich  has  its 
analogue  in  tlie  carpenters'  and  joiners'  bit  and  brace,  and  is  pro- 
pelled by  a  bow-like  portion  which  lies  between  the  handle  and 
the  boring  end.  This  is  the  form  used  by  the  French,  and  which 
they  name  trepan.  The  second  form  of  instrument  is  analogous 
to  an  auger  or  gimlet;  this  is  propelled  by  means  of  a  handle 
which  is  fastened  at  right  angles  to  the  upright  staff  that  is 
fastened  to  the  boring  end.  Instruments  with  other  attachments 
for  propulsion  have  been  invented,  yet  their  complexity  renders 
them  less  easily  used  than  the  two  forms  mentioned,  which  repre- 
sent the  two  species  of  instrument  wliicli  have  been  used  from 
time  immemorial.  The  gimlet-like  instrument  commonlv  used 
by  the  American  and  English  surgeon  is  properly  designated  by 
the  name  trephine,  while  the  other  is  oftener  called  the  trepan; 


TEEPHIXATIOX.  201 

yet  it  should  be  observed  that  these  distinctions  are  not  always 
observed  by  surgeons  and  surgical  writers. 

Whatever  may  be  the  mode  of  propulsion,  the  boring  or  cut- 
ting end  is  similar  in  both  trepan  and  trephine.  This  part  is 
named  a  corona  or  crown;  it  is  cylindrical  in  form,  armed  with 
teeth  like  a  saw.  These  teeth,  like  those  of  saws,  vary  in  form 
and  disposition.  They  are  sometimes  disposed  with  vertical 
intervals  between  them  which  serve  as  spaces  in  which  the  bone- 
dust  collects  as  the  sawing  proceeds.  This  crown  is  often  made 
of  poor  steel,  so  that  the  teeth  break  readily,  and  the  instrument 
becomes  useless.  The  trephine  is,  in  fact,  a  circular  saw,  that 
does  its  work  in  a  horizontal  plane,  instead  of  a  vertical  one;  and 
the  work  may  be  done  by  continuous  motion  in  one  direction,  or 
the  instrument  may  bore  by  half  revolutions,  each  being  the 
reverse  of  the  other  in  direction;  the  latter  is  the  common  mode 
of  propelling  the  trephine.  The  crown  of  the  trephine  rested 
uneasily  both  on  the  head  of  the  patient,  as  well  as  in  the  hands 
of  the  surgeon,  until  it  was  provided  with  a  central  pin  or  pyra- 
mid for  fixation.  This  addition  w^as  made  by  Guy  de  Chauliac 
and  Bichat.  The  crown  is  so  fastened  to  this  pyramid  that  the 
latter  can  be  made  to  ascend  or  descend  below  the  edge  of  the 
crown;  and  wdien  the  descent  is  made,  then  the  crown  is  fixed 
and  forced  to  follow  the  intended  line  of  cutting,  instead  of  slip- 
ping from  side  to  side.  Another  addition  to  the  trephine  is  an 
external  guard,  which  can  be  fixed  at  any  point,  so  as  to  permit 
the  crown  to  penetrate  no  deeper  tlian  is  desired.  From  the 
writer's  experience  this  part,  which  was  attached  to  thetrejDan  by 
Ambrose  Pare,  is  more  embarrassing  than  beneficial;  depending 
upon  it,  the  operator  is  more  apt  to  bore  too  deeply  than  if  he 
were  to  depend  on  his  own  hand  and  eye  to  measure  the  depth. 
There  are  crowns  of  different  sizes;  that  of  average  dimensions  is 
about  half  an  inch  in  diameter;  it  may  be  much  larger,  as  well 
as  much  smaller.  The  crown,  instead  of  being  cylindrical,  may 
be  conoidal  in  form,  and  the  cutting  end  is  the  smaller  portion. 
The  outer  surface  of  this  conoidal  crown  is  provided  wdtli  cutting 
ridges  with  intermediate  furrow^s,  the  arrangement  being  such 
that  the  crowm  cuts  as  much  with  its  outside  as  with  its  free  edge. 
Sometimes  it  becomes  necessary  to  trephine  where  there 
is  a  small  opening  which  must  be  enlarged.  In  such  a  case 
the. central  pyramid  for  fixation  can  not  be  used,  and  one  nnist 
resort  to  another  means  to  retain  the  instrument  in  the  desired 
place.  This  may  be  done  bv  first  boring  with  the  trephine 
14 


20'J  ciJANirM. 

tliroiigli  u  piece  of  leather,  or  a  thin  iiiece  of  lliittencd  wood,  and 
then  i)lacing  this  over  the  point  whicli  is  to  be  trei)hined:  the 
work  being  thus  done  the  instrument  cannot  glide  from  its  place. 

The  operation  of  trephining  after  the  scalp  has  been  shaven 
and  well  cleansed,  consists  of  three  acts,  viz.,  opening  through  the 
skin,  then  perforating  the  skull;  and  a  third  act  is  the  important 
one  of  removing  the  clot  growth,  })us,  missile  or  foreign  body, 
which  is  lodged  within  the  cranium. 

The  skin,  if  covered  with  hair,  should  be  well  shaven,  and 
then  well  washed  with  dilute  alcohol.  The  incision  may  be  made 
with  a  scalpel  or  convex  Idaded  bistoury.  The  form  of  this 
incision  may  be  linear,  crucial,  triangular,  quadrangular,  or  the 
arc  of  a  circle.  The  crucial  cut  is  the  one  usually  reconnnended 
and  made;  of  all  the  forms  it  is  tlie  most  inconvenient,  since  by 
it  four  angular  flaps  are  made,  which  must  be  drawn  aside  during 
the  second  act;  by  any  of  the  other  incisions,  except  the  linear, 
there  is  but  one  flap.  The  semicircular  flap  is  the  one  which  the 
author,  from  his  experience,  especially  recommends;  it  is  easily 
held  aside,  and  after  the  work  is  done,  it  is  readily  restored  to  its 
place  so  that  healing  is  promoted.  The  linear  is  rarely  used, 
since  but  a  limited  portion  of  skull  can  thus  be  laid  bare.  By 
the  semicircular  cut  the  scalp  is  wounded  less  than  by  the  crucial ; 
in  fact,  the  wound  of  the  scalp  by  this  mode  amounts  to  but  little 
more  than  one-half  of  that  produced  by  the  crucial  incision. 

The  primary  semicircular  cut  is  first  made  by  fixing  the  scalp 
by  pressure  with  one  hand,  wdiile  tlie  other  makes  an  incision 
that  extends  at  once  to  the  cranium.  The  flap  should  be  so  con- 
structed that  its  attachment  or  pedicle  is  directed  towards  the 
summit  of  the  head  ;  thus  made  the  wound  will  be  best  situated 
for  the  subsequent  escape  of  materials  that  may  l)e  thrown  ott' 
from  the  wounded  parts.  The  incision  must  reach  to  the  bone, 
so  that  the  flap,  including  the  periosteum,  can  be  uplifted  from 
the  bone.  In  thus  preserving  the  periosteum,  the  possibility  of 
subsequent  osseous  repair  is  favored,  and  thus  the  bone  which  is 
removed  may,  perchance,  be  replaced  by  a  new  growth  of  bone. 

If  the  work  be  done  in  this  way,  it  is  probable  that  the  breach 
made  would  not  be  left  so  imperfectly  closed  as  often  occurs. 
The  flap  thus  incised  can  be  elevated  by  means  of  a  blunt  dis- 
sector, a  thin  chisel  or  the  handle  of  a  scalpel;  and  should  any 
vessels  have  been  divided,  these  should  be  controlled  by  means 
of  torsion  or  ligation. 

The  .sawing  through  of  the  bone  is  next  to  be  done.     The  tre- 


TREPHINATION.  203 

phine  crown  must  first  be  adjusted  for  its  work  by  causing  the 
central  pyramid  to  descend  and  project  about  one  line  beyond  the 
edge  of  the  crown;  also  the  external  guard  if  present  should  be 
fixed  on  the  outside  of  the  crown  at  a  point  corresponding  to  the 
depth  which  it  is  designed  to  bore.  When  the  instrument  is 
thus  adjusted  it  is  placed  on  the  exposed  skull,  and  by  pressure 
and  rotation,  the  pyramid  is  made  to  descend  until  the  crown 
reaches  the  bone  and  its  teeth  so  engage  in  the  wall  that  a  guid- 
ing furrow  is  traced.  At  this  stage,  the  instrument  is  withdrawn 
and  the  pyramid  is  uplifted.  Now  the  crown  is  to  be  placed  in 
the  furrow  that  has  been  traced,  and  the  work  of  sawing  con- 
tinued. The  work  must  be  done  slowly,  and  the  instrument  so 
held  that  it  will  do  equal  work  on  all  sides.  ■  It  should  be  removed 
from  time  to  time,  and  dipped  into  a  dilute  solution  (y^)  of 
corrosive  sublimate,  which  will  have  the  effect  of  rendering  the 
wounded  bone  aseptic,  and  also  to  wash  the  bone-dust  from 
the  teeth  of  the  crown.  This  immersion  has  the  effect  also,  of 
cooling  the  instrument.  It  was  advised  by  Hippocrates  during 
trephining  to  occasionally  withdraw  the  trephine  and  dip  it  into 
cold  water,  for  he  taught,  if  this  were  not  done,  the  bone  would 
be  burnt  by  tlie  boring  crown.  When  the  outer  plate  has  been 
severed  and  the  diploe  reached,  blood  will  escape  from  the  wound, 
due  to  opening  the  diploetic  veins.  In  the  very  old  subject,  in 
whom  the  diploetic  structure  has  disappeared,  little  or  no  signs  of 
blood  will  be  perceived;  and  in  such,  as  the  wall  is  thin,  there 
is  need  of  unusual  care  lest  the  dura  mater  be  injured.  During 
the  work  of  sawing,  the  instrument  should  occasionally  be 
removed,  and  the  progress  of  the  work  be  measured  by  the  intro- 
duction of  a  wire  or  find  sound.  It  is  seldom  that  the  part  tre- 
phined is  of  uniform  thickness;  also  the  unequal  pressure  made 
on  the  instrument,  which  is  difiicult  to  avoid,  causes  the  wall  to 
be  sawn  through  earlier  at  one  point  than  at  another;  and  when 
this  is  perceived,  the  sawing  must  be  continued  slowly  and  the 
remaining  portion  carefully  divided. 

The  case  of  trephining  instruments  contains  also  an  extractor, 
an  elevator  and  a  lenticular  knife,  which  are  used  to  finish  the 
work,  when  the  boring  has  been  done.  When  it  is  found  that 
the  wall  has  been  nearly  perforated,  which  is  perceived  by  the 
slight  mobility  of  the  segment  of  bone  included  in  the  crown, 
then  the  gimlet-like  extractor  may  be  bored  into  the  piece  to  be 
extracted,  and,  perhaps,  in  this  way  it  can  be  removed.  Or,  in- 
stead, a  thin  chisel  can  be  fixed  in  the  sawn  piece,  and  made  to 


204  CRAXUM. 

act  as  a  lever  on.  this,  the  edge  of  the  sawn  skull  serving  as  a 
fulcrum.  By  these  artifices,  tlie  work  can  often  be  completed 
more  safely  than  could  be  done  by  sawing  entirely  through. 
AVlien  the  sawn  portion  has  been  extracted,  the  edge  of  the  open- 
ing must  be  examined,  and  if  fragments  or  spicula  remain  adher- 
ent to  it,  these  must  be  removed;  the  removal  can  be  done  with 
forcej)S,  the  lenticular  knife,  or  a  round  edged  chisel.  Again,  it 
often  occurs  that  the  opening  nuide  is  insufficient  for  the  purpose 
for  which  it  was  intended,  and  then  it  is  necessary  to  enlarge  it. 
The  enlargement  may  be  done  by  Roux's  method  of  evulsion, 
before  described ;  but  if  the  wall  be  thick,  this  work  is  done  witlj 
difficulty  in  this  way.  The  exposure  of  more  surface  is  better 
done  by  again  trephining  near  the  opening  formed,  on  the  side 
towards  which  one  wishes  to  enlarge.  And  if  need  be,  a  third 
adjacent  opening,  and  as  many  more  as  the  case  requires,  can  be 
made,  and  afterwards,  the  small  bridges  of  bone  left  between  the 
orifices  can  be  exsected  with  bone  forceps  or  chisel;  and  thus  an 
elongated  portion  of  the  surface  of  the  encephalon  is  offered  to 
view;  and  through  this  the  surgeon  can  conclude  the  ulterior 
work  of  extraction,  which  is  embraced  in  the  third  stage  of  tre- 
phining. 

There  are  but  few  cases  in  which  there  is  required  a  larger 
opening  than  that  which  is  obtained  by  one  boring;  however, 
an  exceptionally  large  opening  is  sometimes  required  in  the  case 
in  which  the  meningeal  artery  has  been  ruptured;  yet  even  here, 
before  enlargement  of  the  opening  is  done,  an  attempt  should  be 
made  to  remove  the  coagulum  with  a  small  scoop  passed  inwards 
beneath  the  wall.  This  clot  lies  outside  of  tlie  dura  mater,  unless 
the  meningeal  artery  should  be  ruptured  near  its  entrance  at  the 
foramen  spinosura;  then  the  blood  might  flow  inside  of  the  dura 
mater  within  the  arachnoid  sack.  In  this  case,  the  blood  would 
be  hidden  from  view,  and  if  its  unusual  site  were  not  suspected, 
then  tlie  surgeon  would  be  perplexed  to  explain  the  cause  of  the 
compression  which  must  exist  in  such  a  case.  Formerly,  the 
dura  mater  was  never  opened  except  in  very  extraordinary  cases; 
this  rule  is  now  often  transgressed,  in  fact,  so  often  that  it  has 
nearly  ceased  to  be  a  rule.  To  enlarge  the  field  of  cerebral 
exploration,  this  membrane  may  be  opened,  and  in  the  instance 
here  considered,  when  a  clot  is  not  found  outside  of  the  dura 
mater,  the  latter  should  be  opened,  and  the  search  prosecuted 
towards  the  base.  Such  clot,  whether  inside  of  or  outside  of  the 
dura  mater,  should  be  removed ;  yet  aire  should  be  taken  not  to 


TREPHINATION.  2C5 

open  the  rent  in  the  ^vessel  which  has  furnished  the  blood. 
Some  claim  that  it  is  impossible  to  avoid  this,  and  on  that 
account  they  would  prefer  leaving  the  patient  to  his  fate 
rather  than  subject  him  to  an  operation  of  which  the  results,  at 
best,  could  only  be  doubtful;  they  claim  that  the  pressure  on  the 
brain  will  soon  be  tolerated,  and  later,  the  blood  will  be  removed 
by  absorption.  It  is,  however,  better  to  remove  the  coagulated 
blood,  since  even  should  the  material  be  absorbed,  this  would 
occur  slowly,  and  meantime  cause  derangement  in  the  parts 
which  are  pressed  on ;  and  at  best,  a  cyst-like  cavity  would  remain 
in  the  site  of  the  clot.  The  functions  of  the  brain  are  so  impor- 
tant that  a  grave  perversion  of  them  is  a  costly  price  to  pay  for 
the  continuance  of  life;  a  bold  effort  should  be  made  to  escape, 
and  to  secure  freedom  from  such  fetters;  risks  are  not  only  justi- 
fiable to  be  taken,  but  they  become  a  duty  to  both  the  patient  and 
his  surgeon.  If  death  is  better  than  slavery  of  the  body,  how 
much  more  so  is  possible  death  occurring  in  an  attempt  to  escape 
thralldom  of  sensation,  motion  and  mentality,  the  noblest  posses- 
sions of  individual  life.  The  author  would  then  trephine  exhaust- 
ively and  sedulously  remove  the  coagulum,  and  if  there  was 
difficulty  in  arresting  the  bleeding  from  the  ruptured  vessel,  by 
pressure  or  ligation,  then  the  external  carotid  artery  should  be 
tied,  which  would  surely  insure  immunity  from  further  bleeding; 
after  such  ligation  the  surgeon  might  prosecute  the  work  of 
extraction  more  freely;  and,  besides,  the  cavity  might  be  irrigated 
with  an  aseptic  solution,  so  as  to  insure  the  entire  removal  of 
the  extravasated  blood.  In  this  way  the  brain  would  resume  its 
natural  form  and  contour,  and  immediate  recovery  would  probably 
ensue. 

If  the  trephining  be  done  merely  to  elevate  bone  that  has  been 
depressed  by  fracture,  then  the  opening  is  usually  made  contigu- 
ous to  the  sunken  bone;  even  the  edge  of  the  latter  might  be 
embraced  in  the  opening.  Sometimes  the  work  has  been  done 
on  the  depressed  bone  itself;  yet  the  want  of  uniformity  of 
surface  of  the  sunken  bone  renders  it  difficult  to  trephine  there. 
This  work  can  usually  be  done  through  a  single  opening,  when 
the  portion  sawn  has  been  removed,  then  the  work  of  restoration 
of  the  bone  to  its  normal  level  can  be  accomplished  by  the  aid  of 
the  elevator  or  small  lever  that  is  inserted  under  the  margin  of 
the  depressed  bone,  and  the  latter  lifted  into  position.  In  this 
uplifting  care  must  be  used  not  to  contuse  the  under  surface  of 
the  bone  that  is  acted  on.     Another  precaution  to  be  taken  is  not 


200  CRANIUM. 

to  complete  the  fracture  of  the  bone  tliat  is  depressed.  There  is 
less  danger  of  this  occurring  in  the  young  subject  than  in  the  old; 
in  the  latter,  fracture  can  easily  happen.  If  the  uplifted  bone  be 
yet  covered  by  the  periosteum,  it  is  probable  that  its  vitality  will 
be  maintained,  even  though  it  be  marginally  detached. 

In  the  operation  of  trephining  two  important  innovations 
have  lately  been  introduced,  differing  radically  from  the  former 
metiiods.  In  one  of  these,  instead  of  sacrificing  the  disk  of  bone 
that  has  been  excised,  the  latter  is  broken  into  small  frag- 
ments, which,  being  asepticized  by  a  dilute  sublimated  solution, 
are  placed  on  the  breach,  and  the  wound  in  the  scalp  closed  over 
the  opening.  Another  plan  recommended  is  to  asepticize  the 
disk  and  replace  this  entire  on  the  trephined  opening.  Doing 
thus,  it  is  claimed  that  the  breach  in  the  wall  will  be  repaired 
and  the  continuity  of  bone  restored. 

In  the  second  method,  the  work  is  an  osteo-plastic  procedure, 
in  which  the  sawn  segment  is  left  attached  at  one  end  or  side  by 
a  small  pedicle,  so  that  it  can  be  uplifted  like  a  trap  door,  and 
when  the  door  has  served  its  purpose,  it  can  be  lowered  to  nor- 
mal site,  and  thus  the  continuity  of  the  cranial  wall  can  be  })re- 
served.  To  do  the  work  in  this  way,  a  special  saw  is  employed 
by  which  the  wall  is  only  partially  divided,  the  division  except 
the  pedicle  being  completed  by  means  of  the  chisel,  mallet  and 
elevator.     This  method  is  illustrated  in  figure  2. 


Figure  2,  showing  the  osteo-plastic  method  of  trephinin 


Professor  Linn  has  recently  suggested,  as  material  for  reclosing 
the  opening,  decalcified  bone,  and  Frankel  has  proi)0.sed  the  use 
of  celluloid. 

The  writer  has  had  no  experience  in  closing  the  trephined 
opening  by  any  of  the  methods  mentioned,  yet  the  osteo-plastic 
method  appears  rational  and  is  wortli}^  of  trial;  that  of  closure 
by  osseous  fragments  is  more  equivocal  and  should  be  limited  to 
employment  in  the  young  subject. 

In  the  mind  of  the  laity  many  half  truths  have  lived  for  a 


TREPHINATION.  207 

long  time  before  they  developed  into  whole  truths;  the  methods 
of  replacement  just  mentioned  have  such  a  correlate  in  the  popu- 
lar mind,  and  are  answers  to  the  question  which  every  surgeon 
has  heard.  Are  you  going  to  close  the  skull  with  a  gold  or  silver 
plate? 

The  work  having  been  done,  which  was  the  purpose  of  the 
trephining,  viz.,  the  removal  of  a  foreign  body,  clot,  pus  or  tumor, 
the  further  treatment  of  the  wound  will  vary  according  to  the 
condition  of  the  parts  operated  on.  If  they  are  entirely  sound, 
as  they  must  be  when  a  blood-clot  has  been  extracted,  then  after 
cleansing  the  parts  well,  the  wound  can  be  closed  by  means  of 
two  or  more  catgut  sutures.  In  case  the  parts  have  been  lacer- 
ated by  the  penetration  of  a  foreign  body,  then  the  torn  shreds  of 
the  meninges  should  be  excised,  and  the  wound  should  not  be 
completely  closed;  an  opening  should  be  left  for  drainage  through 
a  fenestrated  tube  of  medium  caliber.  If  the  work  has  been  the 
removal  of  a  cerebral  tumor,  then  there  should  also  be  made 
provision  for  the  free  escape  of  excreta  from  the  injured  parts. 
And  such  a  passage  should  be  maintained  open  for  a  considera- 
ble period  of  time.  And  if  the  operation  be  done  to  evacuate  pus, 
then  a  drainage  tube  should  be  inserted  in  the  cavity,  and 
through  the  tube  the  cavity  should  be  cleansed  daily.  The 
patient  should  so  lie  as  to  favor  the  continuous  escape  of  the 
excreted  fluid.  And  the  drain  of  outlet  should  be  so  placed  and 
inclined  as  to  favor  escape.  It  is  rare  that  there  is  closure  by 
immediate  union;  even  in  the  case  in  which  the  trephining  has 
been  done  to  relieve  epilepsy,  immediate  union  is  rare,  and, 
though  it  may  occur,  yet  the  wound  sometimes  reopens  and  a 
sero-purulent  fluid  is  discharged,  often,  for  weeks.  Besides  this, 
the  absence  of  healing  is  sometimes  caused  by  a  fragment  of 
bone  which  detaches  itself  from  the  wounded  wall.  Yet  these 
cases  of  delayed  healing  will  occur  less  frequently  if  the  surgeon 
follows  closely  the  best  methods  of  treating  wounds. 


CIIAITKU   V 


MENINGES     OF     'II I  i-:     lUtAIN. 


When  the  membranes  of  the  brain  are  viewed  by  the  surgeon 
in  reference  to  tiieir  anatomical  structure  and  disposition  for 
practical  considerations,  the  three  normal  meninges  may  be 
reduced  to  two,  for  the  arachnoid  is  connected  to  and  shared  by 
the  other  two;  and  thus  viewed,  we  liave  the  dura  mater,  with 
an  inner  serous  lining,  and  the  pia  mater,  with  an  outer  serous 
lining.  The  dura  mater,  a  fibro-serous  structure,  bears  some 
resemblance  to  an  articular  capsule.  Galen,  in  his  epode,  as  he 
names  it,  on  the  utility  of  parts,  in  which,  as  a  neplus  ultra  tele- 
ologist,  lie  continually  unveils  the  purposes  of  creative  wisdom, 
teaches  that  the  brain  has  three  protective  ramparts,  viz.,  the 
cranium,  the  most  solid  of  all;  then  the  dura  mater,  firm  and 
resistant  but  less  so  than  the  cranial  wall;  and,  lastly,  on  the 
inmost  side,  is  the  pia  mater,  less  firm  than  the  dura  mater;  and 
Galen  thinks  that  these  are  so  disposed  that  each  membrane,  in 
its  turn,  lessens  the  shock  of  impact  against  the  part  which  is 
next  adjacent;  and  so  at  last,  the  solid  skull  is  prevented  from 
injuring  the  brain  which  may  be  carried  against  it  by  any  vio- 
lence. 

Henle,  the  greatest  anatomist  in  modern  times,  as  Galen 
was  in  antiquity,  finds  a  protective  agent  in  the  arachnoidean 
and  subarachnoidean  fluid.  This  liquid,  about  two  ounces  in 
quantity,  rests  on  the  outside  of  the  brain,  and  besides  leveling 
the  inequalities  on  the  surface  of  the  brain,  it  is  interposed  as  a 
thin  film  between  the  organ  and  the  cranial  wall  covered  by  the 
dura  mater.  The  prophylactic  agencies  mentioned  are  powerless 
against  violent  injury;  they  are  only  efficient  against  mild  shocks, 
such  as  may  arise  from  brisk  or  sudden  movements  of  the  head. 

Besides  its  protective  agency,  the  dura  mater  performs  other 

offices  in  the  animal  economy;  it  is  the  periosteal  investment  of 

the  inner  surface  of  the  skull ;  yet,  different  from  other  periosteum, 

there  resides  in  it  but  little  bone-producing  power;  and  this  is 

(208) 


AFFEGTiO^'S    OF    THE    MEMBKAXES    OF    THE    BRAIN.  209 

contrary  to  that  which  might  have  been  expected,  since  it  is  more 
vascular  than  normal  periosteum.  A  third  office  of  this  mem- 
brane is  to  receive  the  blood  from  the  brain  in  the  sinuses  or  res- 
ervoir-like channels  which  lie  in  it.  The  blood  is  brought  bv 
veins  from  the  subjacent  brain,  and  emptied  into  the  sinuses,  and 
the  course  of  the  blood  in  these  veins  is  opposite  to  that  in  the 
sinuses:  the  seeming  effects  of  which  would  appear  to  be  to 
retard  tlie  outward  passage  of  the  blood,  and  thus  to  avert  sudden 
cerebral  anaemia,  wliich  might  otherwise  occur. 

The  veins  that  convey  the  blood  from  the  brain  to  the  sinuses 
in  the  dura  mater  are  valveless  and  remarkable  for  their  fragility: 
conditions  which  favor  the  easy  passage  of  blood  as  well  as  their 
rupture  and  effusion  of  blood. 

To  the  dura  mater  the  function  of  producing  bone  has  been 
generally  denied  by  anatomists:  and  hence  the  explanation  of  the 
fact  that  where  portions  of  the  wall  of  the  skull  have  been 
removed  by  the  trephine,  or  by  accident,  the  breach  remains 
afterwards  unfilled  by  bone.  From  study  of  tljis  matter  by 
Ballon,  of  Strassburg,  in  1864,  it  is  probable  that  if  more  effort 
were  made  to  preserve  the  integrity  of  the  dura  mater,  there 
might  be  a  reproduction  of  bone;  in  such  cases  Ballon  refers  to 
experiments  which  have  been  made  by  Oilier  and  Flourens,  in 
which  these  men  have  proven  that  the  outer  surface  of  the  dura 
mater  can  generate  bone.  From  an  examination  of  the  speci- 
mens in  the  medical  museum  of  Strassburg,  Ballon  is  convinced 
that  the  dura  mater  can  generate  bone,  both  from  its  outer  and 
its  inner  surface.  This  writer  thinks  that  the  serous  epithelial 
lining  of  the  inner  surface  of  the  dura  mater  must  be  unfavorable 
to  the  production  of  bone.  And,  furthermore,  were  bone  devel- 
oped in  the  inner  surface,  it  could  serve  no  physiological  purpose; 
and,  further,  that  its  position  then  would  endanger  the  contiguous 
cortical  surface  of  the  brain. 

SURGICAL    AFFECTIONS    OF    THE    MEMBRAXES    OF    THE    BRAIX. 

The  meninges  of  the  brain  in  their  diseases  and  derange- 
ments offer  a  common  field  to  surgeons  and  physicians,  the 
greater  share  falling  probably  to  Internal  Medicine. 

Inflammation  of  the  dura  mater,  though  pertaining  rather  to 
the  province  of  the  physician,  finds,  also,  a  place  in  the  works  of 
modern  surgery.  It  has  received  the  name  of  pachymeningitis; 
also  of  scleromeningitis ;  though  the  latter  is  the  more  appropriate, 
yet  the  former  name  is  the  more  usual  one.     Pachymeningitis 


21U  MKMiniANKS    OF    TIIK    BRAIN. 

may  be  caused  by  a  wound,  or  external  violence.  A  peculiar 
form  of  it  is  that  which  can  originate  from  excessive  and  pro- 
longed alcoholism. 

If  violence  injures  the  cranial  wall  in  its  entire  thickness, 
the  dura  mater  must  share  in  the  lesion.  The  membrane  may  be 
contused,  torn,  or  a  portion  of  its  structure  may  1)0  lost. 

The  treatment  of  such  injury  must  necessarily  be  comprised 
in  the  general  management  of  the  wound  of  the  head  of  which 
it  is  but  a  part.  Similar  to  the  course  recommended  in  the  treat- 
ment of  the  scalp,  it  should  be  the  aim  to  preserve  all  that  is 
possible  of  the  membrane,  since,  similar  to  the  skin  or  mucous 
membrane,  when  a  portion  of  the  dura  mater  is  lost,  it  cannot 
be  restored  again.  The  tissue  of  rejiair  is  at  best  but  cicatricial 
structure,  which  here,  as  eLsewhere,  contracts,  compresses,  and 
changes  somewhat  the  form  of  the  parts  with  which  it  is  contigu- 
ous. Here  the  rule  must  be  to  save  some  torn  shreds  of  the  dura 
mater,  if  it  is  probable  that  the}^  wnll<  retain  their  vitality.  As 
the  membrane  is  vascular,  and  if  wounded  at  certain  points, 
hemorrhage  must  result,  hence  such  opened  vessel  when  acces- 
sible must  be  ligated;  or  if  that  be  not  possible,  for  example 
where  the  vessel  lies  partly  imbedded  in  the  bone  as  well  as  in 
the  dura  mater,  then  the  torn  vessel  may  be  closed  by  plugging 
it  with  a  small  piece  of  sponge.  Asepticised  white  wax  might 
be  used  as  closing  material.  The  small  mass  of  occluding  mate- 
rial would  afterward  remain  as  harmless  matter. 

The  dura  mater  can  be  injured  by  blows  on  the  skull  in 
which  the  latter  is  not  fractured,  and  still  the  subjacent  mem- 
brane is  contused,  and  possibly  detached  from  the  wall.  The 
result  of  such  injury  may  be  the  opening  of  a  blood  vessel, 
and  the  effusion  of  blood  between  the  membrane  and  the 
skull.  Such  effused  blood  may  disappear  mostly  by  absorption, 
yet  the  result  will  be  a  prolonged  irritation  of  the  part,  and,  as  a 
consequence,  a  thickening  of  the  membrane,  and,  sometimes,  a 
production  of  bone.  The  osseous  growth  can  be  merely  a  thin 
plate  on  the  outer  surface  of  the  dura  mater,  or  it  may  be  a  spine- 
like development,  which  by  its  presence  may  maintain  a  local 
irritation  of  the  adjacent  surface  of  the  brain.  Such  an  irritant 
might  become  the  cause  of  epilepsy.  Again,  a  large  clot  of  blood 
might  not  be  wholly  absorbed,  the  solid  elements  of  the  coagulum 
remaining,  and  deforming  the  surface  against  which  the  brain 
rests.  Nature,  in  her  efforts  to  restore  parts  to  their  normal  form, 
is  in  most  cases  competent  to  remove,  or  compensate  the  results 


AFFECTIONS    OF    THE    MEMBRANES    OF    THE    BRAIN.  211 

of,  the  injuries  just  considered.  Still,  in  the  study  of  the  diseases 
of  the  brain  and  nervous  system  in  their  protean  forms,  a  possi- 
ble origin  from  some  lesion  of  the  species  mentioned  should  be 
borne  in  mind;  and  as  means  of  relief,  should  there  be  a  localized 
guide,  exploratory  trephination  might  be  resorted  to. 

The  observation  was  made  some  years  ago  that  inflammation 
of  the  dura  mater  may  originate  from  the  prolonged  use  of  alco- 
holic drinks.  In  such  cases  the  inner  face  of  the  membrane  is 
principally  affected.  Among  those  authorities  who  have  particu- 
larly studied  this  disease  may  be  mentioned  the  names  of  Grie- 
singer,  Lancereaux,  Virchow,  and  Vulpian.  Griesinger,  in  1862, 
wrote  on  the  subject  from  the  observation  of  eight  cases.  In  most 
of  the  cases  there  were  headache,  narrowness  of  the  pupil,  somno- 
lence, and,  in  a  few  cases,  palsy.  But  where  effusion  of  blood 
occurred,  the  attendant  symptoms  were  more  obscure  and  compli- 
cated; for  after  such  hemorrhage,  there  ma}'  be  convulsions,  anaes- 
thesia, and  idiocy,  as  the  result  of  cerebral  changes.  He  found 
the  disease  usually  in' drunkards  who  were  over  fifty  years  of 
age.  The  patient  may  recover,  and  then  there  will  remain  pig- 
mentary traces  of  the  preexistent  hemorrhage. 

In  1863  Lancereaux  published  his  studies  and  observations, 
and  he  is  the  leading  authority  on  the  subject.  He  assigns  a 
varied  causation  for  2)achymeningitis,  viz.,  that  it  may  arise  from 
alcoholism,  traumatism,  rheumatism,  erysipelas,  cancer,  tubercu- 
losis, scrofula,  and  rachitis.  Old  age  and  infancy  are  predispos- 
ing agencies.  Continued  encephalic  congestion  caused  by  the 
excessive  use  of  spirituous  drinks  seems  to  have  been  the  most 
frequent  cause.  And  that  alcohol  can  act  thus  has  been  demon- 
strated by  Kremia.nsky  and  Neumann  in  experiments  on  dogs, 
which  were  given  large  amounts  of  alcohol.  In  these  animals  it 
was  found  that  the  administration  of  alcohol  for  the  period  of 
four  weeks,  caused  an  inflammation  of  the  dura  mater. 

The  prominent  condition  present  in  the  disease  is,  in  some 
cases,  a  neoplastic  formation  rich  in  blood-vessels  remarkable  for 
the  thinness  and  fragility  of  their  walls.  In  other  cases  there  is 
found  clotted  blood,  as  well  as  membranous  structure. 

From  a  study  of  the  pathological  conditions,  which  have  been 
revealed  by  necropsies  of  fatal  cases  of  pachymeningitis,  it  has 
been  found  that  there  results  from  the  inflammation  a  connective 
tissue  growth  on  the  inner  face  of  the  dura  mater.  The  usual 
site  of  this  is  beneath  the  cranial  vault,  and  is  near  the  falx 
major  cerebri.     The  structure  developed  is  analogous  to  that  of 


•_'12  MKMr.RANES   OF    THE    BRAIN. 

ordinary  graiiulativo  tissue-  it  is  extremely  vascuiar.  Tlie  fragile 
nature  of  these  vessels  disposes  them  to  rupture  and  effusion  of 
blood.  The  effusion,  if  small  in  quantity,  may  remain  pent  up, 
or  inclosed  in  the  new  growth;  but  if  it  be  larger  in  amount, 
then,  after  a  time,  a  fine  membrane  is  developed  over  it,  which 
some  observers  think  is  a  continuation  of  the  adjacent  arachnoid. 
There  niay  be  a  large  amount  of  blood  poured  out  at  once,  or 
there  may  occur  successive  ruptures,  so  that  coagula  of  ditlcrent 
ages  may  be  found.  Possibly,  these  a]>oj)lectic  effusions  of  blood 
may  originate  in  spontaneous  rupture  of  the  vessels;  it  is  more 
probable,  however,  that  the  vessels  are  opened  through  transmitted 
violence.  The  growth,  in  such  near  proximity  to  the  cortex  oi' 
the  brain  in  which  the  motor  centres  lie,  must  induce  some  func- 
tional disturbances  of  these  centres,  and  hence  the  patient  will  be 
liable  to  other  injury  from  stumbling,  fall,  or  some  kindred  acci- 
dent. And  for  similar  reasons,  the  a})Oj)lectic  effusion  having 
occurred  once,  predisposes  to  other  attacks.  And  in  this  work  it 
is  clear  that  alcoholism  is  no  mean  adjuvant,  both  in  causing 
meningeal  congestion,  and  in  toppling  the  patient  to  the  ground. 

Pachymeningitis  presents,  according  to  its  stage,  different  sub- 
jective symptoms,  viz.,  irritation  and  depression.  In  its  early 
period  the  symptoms  are  that  of  irritation  and  excitation;  and 
this  stage,  which  may  be  long  or  brief,  corresponds  to  the  period 
when  the  neoplasm  is  developing.  In  this  stage  tlicre  is  often  a 
headache  excruciating  in  character:  such  cephalalgia  when 
unaccompanied  by  fever,  and  yet  is  continued  for  a  long  time, 
according  to  Abercrombie,  indicates  inflammation  of  the  dura 
mater.  The  pain  is  located  in  the  region  of  the  new  growth. 
There  is  also  vertigo,  with  ringing  of  the  ears,  disturbed  sleep, 
and  nightmare.  Sometimes  there  is  a  sensation  of  a  floating 
wave  in  the  head.  The  power  of  speech  is  interfered  with  in 
some  instances.  A  symptom  observed  by  Griesingeron  which  ho 
lays  much  stress,  is  myosis,  or  narrowing  of  the  pupils.  The  irri- 
tative period  is  of  variable  duration,  viz.,  for  only  a  few  weeks, 
or  it  may  continue  for  months. 

The  second  period,  viz.,  that  of  depression,  is  noted  for  the 
general  adynamic  character  of  the  morbid  phenomena  })resent. 
It  may  appear  suddenly,  or  its  advent  can  be  so  gradual  that  it 
is  unpercei  ved.  The  ai)Oi)lectic  effusions  can  occur  consecutively 
and  in  such  slight  amount  that  the  brain  tolerates  them,  and 
scarcely  any  depression  is  present.  This  rupture  of  the  vessels 
and  the  pouring  out  of  the  blood  causes  sharp  pain.     Such  pain 


AFFECTIONS    OF    THE    MEMBRANES    OF    THE    BRAIN.  213 

arises  from  the  sensory  function  of  the  dura  mater,  which  the 
author  has  seen  demonstrated  many  times  hy  Flourens,  who  first 
discovered  this  property  of  the  dura  mater;  the  great  vivisection- 
ist  never  referred  to  this  addition  to  physiology  without  a  visible 
display  of  vanity.  The  more  recent  observation  of  Vulpian 
that  there  are  developed  nerve  fibers  in  the  vascular  neoplasm, 
furnishes  an  explanation  of  the  pain  felt  when  the  growth  rup- 
tures. This  stage  is  characterized  by  the  somnolence  wliich  attends 
it;  the  patient  often  sleeps  for  twenty-four  or  thirty  hours.  And 
when  he  awakes  there  is  still  drowsiness  present.  During  this 
stage  the  pupil  remains  narrowed,  as  in  the  first  period;  but,  dif- 
ferent from  the  first  stage,  when  rupture  has  occurred,  the  pupil 
of  the  eye  on  the  side  of  the  rupture  is  more  contracted  than  on 
the  other  side.  When  awakened  the  patient  still  complains  of 
headache.  The  pulse  is  slow  and  irregular.  And  there  is  per- 
ceived still  the  same  sensation  of  something  floating  in  the  head 
which  was  complained  of  early  in  the  disease.  The  symptoms 
described  are  those  arising  from  a  diff'used  or  extended  clot,  occu- 
pying a  considerable  space  of  the  cerebral  cortex;  in  another 
class  the  clotted  blood  occupies  a  limited  extent  of  surface.  In 
the  diffused  form  the  symptoms  of  depression  reveal  themselves 
in  palsy  affecting  a  large  portion  of  the  body.  Yet  certain  parts 
may  be  less  palsied  than  others.  There  may  be  comj)lete  hemi- 
plegia of  one-half  of  the  body,  and  incomplete  paralysis  of  the 
other  side;  this  would  indicate  a  clot  on  each  side,  one  being 
larger  than  the  other.  Again,  if  the  clot  be  definitely  localized, 
then  the  palsy  will  be  less  diffused  in  its  manifestation,  viz.,  a 
certain  part  of  the  body  will  be  affected.  And  in  all  cases  the 
paralysis  produced  is  less  permanent  and  more  incomplete  than 
that  which  arises  from  an  intra-cerebral  effusion  of  blood. 

Pachymeningitis  has  been  seen  in  the  infant;  the  neoplasm 
pursues  the  same  course  as  in  the  adult;  the  vessels  burst  and  a 
clot  of  blood  is  formed  on  the  subjacent  surface  of  the  brain; 
more  frequently,  however,  the  growth  resulting  from  the 'inflam- 
mation does  not  burst,  but  there  is  merely  a  serous  effusion. 
Such  disease  in  the  infant  falls  more  often  to  the  care  of  the 
physician  than  to  the  surgeon. 

The  hemorrhagic  effusion  from  pachymeningitis  limits  its 
action  chiefly  to  a  perversion  of  motion;  the  sensory  function  of 
parts  is  rarely  affected  by  it.  The  morbid  manifestations  have, 
as  a  rule,  occurred  on  the  side  opposite  to  the  apoplectic  effusion; 
still  there  have  been  noted  exceptions  to  this  observed  by  A'^irchow 


214  MK.MI'.IIANKS    1)1-'    THK    I'.JiAIX. 

;ui<l  Wood;  the  paralysis  and  clot  were  on  tlie  same  side  of  the 
body. 

Pachymeningitis  when  it  reaches  the  hemorrhagic  or  dej)ressed 
stage,  nearly  always  destroys  life.  Still  in  the  necropsies  which 
have  been  made  in  fatal  cases,  not  unfrequently  there  have  been 
fonnd  conditions  of  the  parts  which  indicate  that  there  had 
occurred  a  rupture,  from  which  the  parts  were  in  process  of 
recovery;  through  absorption  an  old  clot  had  been  nearly  removed; 
there  remained  only  pigmentary  remnants.  Such  a  favoraljle 
event  is  too  rare  to  materially  change  the  inauspicious  prognosis 
usually  coupled  with  this  disease. 

Treatment. — This  may  be  medical  or  surgical.  Along  with 
the  removal  of  any  discoverable  causal  agency,  as  remedial  means, 
one  may  give  intestinal  and  renal  derivatives.  As  a  purge, 
calomel  is  one  of  the  best.  And  to  act  both  as  diuretic  and 
absorbent,  there  may  be  given  the  iodide  of  potassium.  For  the 
same  purpose,  the  arseniate  of  soda  is  advised  by  Charcot.  Local 
derivatives,  as  irritants  and  pustulating  agents,  may  be  tried. 

Inasmuch  as  the  means  which  have  been  mentioned  have 
proved  unavailing,  and  have  scarcely  cured,  the  question  arises. 
Is  this  not  a  field  wdiere  surgery  may  intervene  and  extend  to  the 
patient  a  more  helpful  hand  than  internal  medication  has  thus 
far  offered?  As  the  trephine  lias  pioneered  the  way  by  which 
cerebral  tumors  may  be  reached,  so  it  may  open  the  way  by 
which  an  equally  intractable  malady  may  be  directly  reached 
and  directly  combated.  The  attack  by  means  of  remedies  given 
internally  is  like  that  of  besiegers,  desultory  and  indirect,  and 
like  them  the  surgeon  would  act  more  rationally  by  opening  a 
breach  through  the  wall,  even  though  it  be  at  greater  peril;  for 
thus  he  could  meet  the  eneniy  hand  to  hand.  Perhaps  it 
might  be  urged  that  the  s\'mptomatic  evidences  of  the  pachymen- 
ingitis are  too  obscure  to  justify  a  resort  to  the  trephine.  The 
.symptoms  are  not  more  obscure  than  are  those  presented  in  the 
case  of  the  intracranial  tumor.  One  would  not  be  justified  in 
trephining  before  the  second  stage  of  the  disease,  in  which  the 
condition  of  the  patient  indicated  rupture  of  the  new  vascular 
growth:  viz.,  motor  disturbances,  general  or  localized,  according 
as  the  effusion  was  spread  out  over  an  extensive  surface  or  con- 
fined to  a  limited  point  of  the  cortex.  The  localizing  of  such  a 
clot  can  be  done  more  surely  than  in  most  cases  of  tumor.  The 
neoplasm,  and  consequently  a  coagulum  arising  from  its  rupture, 
must  alwavs  be  on  one  side  of  the  cranial  vault.     Hence  should 


EXTERNAL  PACHYMEXINGITIS  OF  PUERPERAL  ORIGIN.  215 

this  be  one  of  those  anomalous  cases  in  whicli  the  clot  and  palsy 
are  on  the  same  side,  the  trephining  could  readily  be  repeated 
on  the  opposite  side. 

As  trustworthy  indications  for  operating,  besides  a  continuous 
cephalagia,  would  be  a  persistent  narrowness  of  the  pupils,  and  a 
slow  pulse.  And  some  corroborative  evidence  might  be  furnished 
by  the  history  of  the  case.  The  opening  should  be  made  with  a 
large  trephine  through  the  parietal  bone,  just  outside  of  the  lon- 
gitudinal sinus.  As  soon  as  the  dura  mater  is  reached,  its  condi- 
tion might  confirm  the  diagnosis,  yet  whether  this  be  so  or  not, 
an  opening  should  be  made,  and  the  clot,  if  discovered,  should 
be  removed.  For  this,  a  sf)oon-shaj)ed  curette  may  be  used. 
Should  no  coagulation  be  found,  in  a  patient  in  whom  there 
were  strongly  marked  signs  of  effusion,  then  one  would  be  justi- 
fied in  operating  on  the  ojDposite  side;  and  should  nothing  be 
found  there,  still  the  surgeon  w^ould  have  the  satisfaction  of  hav- 
ing neglected  notliing  for  the  relief  of  the  patient. 

External  Pachymeningitis  of  Puerperal  Origin. — A  singular 
form  of  inflammation  of  the  dura  mater,  of  which  observations 
Avere  jDublished  by  Rokitansky  in  1838,  is  one  associated  with  the 
puerperal  female.  The  inflammatory  action  seems  to  confine  its 
action  to  the  outer  surface  of  the  membrane.  This  morbid  process 
has  been  observed  in  every  period  of  the  puerperal  subject,  from 
the  third  month  on  to  the  close  of  gestation.  Instead  of  tlie 
vascular  growth,  which  from  other  causes  we  have  seen  occurring 
on  the  inner  face  of  the  dura  mater,  in  this  form,  the  neoplastic 
formation  tends  to  ossification  on  the  outside  of  the  membrane. 
It  has  been  observed  in  different  stages  of  development,  from  a 
soft  gelatinous  material,  to  one  in  whicli  the  latter  has  become 
organized  into  cartilaginous,  and  finally  into  osseous  material. 
It  is  evident  that  the  dura  mater  when  inflamed  acquires  a 
duplicate  faculty:  viz.,  on  its  inner  side  it  can  develop  a  vascular 
structure,  while  on  its  external  face,  it  can  discharge  the  oflEice  of 
a  periosteum,  in  jDroducing  bone.  How  the  puerperal  condition 
can  arouse  this  osteo-genetic  action  is  unknown;  perhaps  it  may 
be  caused  by  the  displacement  of  the  blood  towards  the  upper 
part  of  the  body  through  the  encroachment  of  the  developing 
uterus  on  the  abdominal  cavity. 

The  new  growth  of  bone  appears  along  the  regions  adjacent  to 
the  sagittal  and  coronal  sutures  ;  it  is  especially  abundant  along 
the  course  of  the  middle  meningeal  artery.  In  some  cases  the 
growth  is  so  extensive  as  to  occupy  the  entire  inner  surface  of  the 


210  MKMIIKANES    OF    THK    IJKAIX. 

cranial  vault.  A  remarkable  feature  of  this  osseous  product  is 
that  it  is  separated  from  the  inner  plate  of  tiie  skull  by  a  diploctic 
structure.  It  is  also  found  sometimes  stratilied,  tlie  different 
layers  corresponding  to  and  denoting  a  pregnancy.  This  osseous 
growth  varies  in  tliickness  in  different  skulls  from  the  thinnest 
lamella  to  a  layer  one  line  in  thickness.  There  has  been  observed, 
in  some  cases,  a  similar  growth  of  bone  on  the  outside  of  the  skull 
corresponding  in  site  to  that  on  the  inside.  These  osteophytic 
enostoses  and  exostoses  are  singularly  interesting,  from  the  fact 
that  they  are  the  chronicles  of  pregnancy,  the  child  recording  its 
foetal  life  in  the  enduring  tablets  of  the  maternal  cranium.  If 
nature  in  her  structural  handiwork  had  shifted  to  the  side  of 
paternity  this  recording  tablet,  she  would  have  shown  a  fairer 
division  of  labor  connected  with  the  continuation  of  our  species. 

As  clinical  conditions  of  the  puerperal  state  referable  to  the 
encroachments  of  tliese  osteophites  on  the  brain  are  the  headache 
and  vomiting  which  so  often  aiiect  the  pregnant  woman;  condi- 
tioiis  dependent  more  on  local  congestion  than  on  cerebral  conges- 
tion; in  fact,  the  growth  of  bone  is  too  gradual  in  its  formation, 
and  too  limited  in  amount,  to  cause  compression  of  tlie  adjacent 
brain.  In  those  days  when  the  lancet  did  not  contract  rust 
through  disuse,  the  contributions  of  blood  which  the  puerperal 
woman  was  accustomed  to  make,  doubtless,  in  reducing  the 
amount  of  blood,  lessened  or  wholly  j^revented  the  amount  of  this 
osseous  formation,  in  removing  the  materials  for  its  formation. 

As  treatment  which  miglit  be  pursued  against  this  osseous 
deposit,  the  most  rational  one  would  be  absorbents;  iodine  in 
some  form,  and  likewise  mercury,  might  be  employed.  For  this 
purpose,  the  iodide  of  potassium  may  be  administered  internally; 
externally,  the  tincture  of  iodine  might  be  painted  over  the 
regions  in  which  the  bony  material  is  deposited.  Ji.  solution  of 
the  biniodide  of  mercury  might  be  given  internally.  The 
author,  however,  would  say  that  it  is  rare  that  it  would  be  justi- 
fiable to  interfere  witli  the  puerperal  condition  by  way  of  the 
plans  of  treatment  here  referred  to;  only  in  cases  of  violent 
continuous  cephalalgia  in  phlethoric  subjects,  would  it  be 
prudent  to  abstract  blood,  and  check  the  neoplastic  tendency  by 
the  use  of  iodine  externally  and  internally. 

Tumors  of  the  Dura  Mater. — It  is  rare  that  the  dura  mater  is 
the  site  of  tumors,  whether  benign  or  malignant.  It  is  true  that 
it  is  not  infrequently  penetrated  or  encroached  on  by  growths 
which,  originating  on  the  scalp,  grow  inwards,  or  which,  arising 


TUMORS  OF  THE  DURA  MATER.  217 

from  the  brain  itself,  grow  outwards  and  involve  the  meninges; 
jet  the  cases  are  much  rarer  in  which  the  prime  starting  point 
is  from  the  membranes.  Nevertheless,  in  recent  times,  since 
Pathology  as  a  science  has  become  more  accurate,  frequent 
instances  in  which  tumors  have  originated  in  the  meninges  have 
been  noted. 

Meningeal  tumors  differ  in  respect  to  their  points  of  origin, 
their  mode  of  development,  their  structure,  and  the  symptoms  to 
which  they  give  origin.  In  regard  to  their  classification  there 
exists  much  discord  among  the  pathologists;  the  leading  generic 
names  formerly  were  cancer  and  fungus  of  the  dura  mater.  From 
these  the  sarcoma  was  afterwards  separated;  and  from  the  latter, 
Robin  detached  the  epithelioma,  which,  he  claims,  arises  from  the 
arachnoid  membrane,  while  the  sarcoma,  consisting  of  fibro-plastic 
elements,  originates  in  the  dura  mater.  Others,  as  Virchow,  deny 
that  any  of  these  tumors  are  of  the  nature  of  epithelioma. 

From  a  study  of  these  growths  Jaccoud  and  Labadie-Lagrave 
have  classed  them  under  three  general  divisions:  (1)  Accidental, 
(2)  Parasitic,  and  (3)  Constitutional. 

Those  of  the  accidental  class  may  be  composed  of  elements 
similar  to  those  whence  they  spring;  or  the}'  may  consist  of 
elements  different  from  the  structures  whence  they  arise.  Subdi- 
visions of  this  group  are  fibroma,  sarcoma,  epithelioma,  myxoma 
lipoma,  chondroma,  osteoma,  and  calcareous  concretions. 

The  fibroma  has  its  representative  in  the  Pacchionian  corpuscles, 
which  are  revealed  to  the  necropsist  in  almost  every  case  of 
autojDsy  on  an  adult.  Besides  these,  there  is  a  form,  after  vascu- 
lar, which  springs  up  on  the  inner  face  of  the  dura  mater,  beneath 
the  arachnoid.  The  fibers  of  these  tumors  are  arranged  concen- 
trically; it  is  round  or  oval  in  form,  and  may  vary  from  the  size 
of  a  pea  to  that  of  an  orange. 

The  sarcoma  occurs  in  the  dura  mater  in  a  form  designated 
angiolithic  (Ranvier).  This  form  consists  of  attenuated  fibers, 
traversed  by  vessels  which  are  varicosed ;  or  its  component  ele- 
ments may  contain  also  sand-like  material,  similar  to  what  occurs 
in  the  choroid  plexus.  This  sand-containing  growth  is  named  by 
Yirchow,  psammoma.  Gintrac,  who  has  studied  these  meningeal 
tumors,  finds  that  sarcoma  occurs  oftener  in  the  membranes  than 
in  the  brain  itself.  Of  thirty-two  sarcomata  collected  by  him, 
nineteen  were  seated  in  the  dura  mater,  and  most  commonly 
such  tumor  is  seated  at  the  base,  and  there  presses  on  the  chiasm 
of  the  optic  nerves.  The  tumor  often  grows  towards  the  skull, 
and  it  may  perforate  the  latter  and  appear  on  the  outside. 
15 


218  MEMBRANES    OF    THE    BRAIN. 

Epithelioma. — Some  discord  exists  among  pathologists  concern- 
ing the  question  of  epitliehoma  of  the  meninges  of  tlie  brain;  its 
existence  is  denied  by  some.  It  is  clear  that  the  growths  whicli 
have  been  so  classified  do  not  conform  histologically  to  what  is 
commonly  recognized  as  epithelioma.  But,  adopting  the  opinions 
of  Cornil  and  Ranvier,  there  are  two  varieties  of  the  growth, 
pearly  or  nacreous,  and  the  papillary.  Tlie  first  species  has  a 
thin  covering;  it  is  vaguely  fibrillated,  and  its  content  is  disposed 
in  concentric  layers.  When  this  structure,  which  is  of  irregular 
form,  is  examined  it  is  found  to  consist  of  epidermal  cells  which 
have  undergone  fatty  degeneration.  Both  the  content  and  its 
outer  coat  contain  no  vessels.  In  the  second  form,  the  tumor  is 
constituted  of  papillDe,  and  covered  by  a  coat  of  epithelial  cells. 
Again,  tumors  have  been  observed  here  which  were  composed  of 
strata  of  pavement-celled  epithelium. 

The  myxoma  has  seldom  been  seen  arising  from  the  meninges; 
it  is  found  oftener  in  the  brain  itself  It  is  composed  of  mucous 
tissue,  of  which  the  constituent  cells  are  large,  pale,  fusiform,  and 
often  anastomose.  The  myxoma  is  oftenest  found  on  the  con- 
vexity of  the  hemispheres. 

The  lipoma  has  been  often  observed  arising  from  the  meninges; 
more  rarely  it  has  been  found  in  the  brain.  As  Parrot  observes, 
it  is  hard  to  explain  the  presence  of  fatty  tumors  in  the  brain 
when  one  remembers  that  there  is  no  fatty  matter  in  the  brain,  or 
in  its  membranes.  Yet  Parrot  found  a  lipoma  arising  from  the 
pia  mater  of  a  child.  This  growth  was  three  inches  long  and  a 
third  of  an  inch  thick.  It  was  yellow  in  color,  and  proved  to  be 
fatty  matter  when  analyzed.  The  lipoma  has  been  seen  arising 
from  the  meninges  by  Virchow,  Home,  and  Meckel ;  still  it  is  not 
of  common  occurrence. 

The  chondroma  can  arise  from  the  inside  of  the  skull;  also 
from  the  meninges.  Like  the  lipoma  it  rarely  occurs.  Accord- 
ing to  Gintrac,  this  tumor  has  been  found  usually  in  young  sub- 
jects. 

Osteoma. — Besides  the  osteoma  of  puerperal  origin  hitherto 
mentioned,  the  dura  mater  is  the  site  of  osseous  formations,  which 
may  appear  at  any  point;  the  membrane  seems  to  undergo  ossi- 
fication; thus  the  tentorium  has  been  seen  almost  wholly  con- 
verted into  bone.  Again,  the  dura  mater,  where  it  lines  the 
vault  of  the  cranium,  may  become  almost  wholly  ossified.  Osse- 
ous growths  may  appear  also  in  the  cerebral  falx.  The  osteoma 
may  also  appear  on  the  arachnoid  membrane;  here  lamella)  oi 


CONSTITUTIONAL    TUMORS.  219 

bone  have  been  found,  armed  on  their  inner  surface  with  stalac- 
tite-like processes.  The  arachnoidean  osteoma  is  oftenest  situated 
over  the  convex  surface  of  the  brain,  and  especially  on  the  ante- 
rior lobes.  The  meningeal  osteoma  occurs  independently  of  age, 
since  it  is  often  found  in  the  young;  even  at  birth  it  has  been 
seen. 

Psammoma. — Calcareous  growths  have  been  fou-nd  in  the  men- 
inges, and  the  formation  as  described  by  Virchow  may  appear  in 
two  forms;  in  one,  the  growth  in  cylindrical,  sj^inous  or  globular 
form,  is  closely  connected  with,  and  ensheathed  as  it  were  in,  con- 
nective tissue;  but  in  the  other  species  the  sand-like  material 
lies  loose  in  the  structure,  and  can  easily  be  detached.  Such  con- 
cretion can  attain  considerable  dimensions.  Bergmann  has  seen 
one  as  large  as  a  walnut.  The  tumor  is  hard,  smooth,  and  of  a 
reddish  white  hue.  The  action  which  such  tumor  can  have  on 
the  brain  depends  on  its  situation;  its  influence  is  greatest  when 
it  lies  at  the  base,  where  the  superincumbent  brain  is  caused  to 
atrophy.  Or  functional  disturbance  of  nerves  can  be  caused  by 
such  pressure. 

Parasitic  Tumors. — Of  this  class  of  meningeal  tumors  there  are 
two  species:  the  cysticercus  and  the  echinococcus. 

The  cysticercus  occurs  in  the  pia  mater.  Nineteen  cases  have 
been  collected  by  Gintrac.  The  vesicular  growth  arising  from 
this  parasite  may  attain  the  volume  of  a  pigeon's  egg.  The 
tumor  finally  undergoes  a  fatty  change;  and  in  this  detritus  there 
are  found  fragments  of  the  parasite. 

The  cyst  from  the  echinococcus  is  usually  more  voluminous 
than  that  of  the  cysticercus;  and  there  are  seldom  found  more 
than  two  or  three  cysts.  The  containing  wall  is  fibrillated  in 
structure,  and  contains  vessels.  This  cyst  in  the  cranium  may  be 
coincident  with  similar  ones  in  the  body.  The  author  has  seen 
an  instance  of  echinococcus  cyst  on  the  convex  surface  of  the 
brain.     The  tumor  was  somewhat  larger  than  a  cherry. 

Constitutional  Tumors. — Carcinoma  occurs  more  rarely  in  the 
membranes  than  in  the  brain  itself.  When  of  meningeal  origin, 
it  can  attain  large  dimensions,  even  some  inches  in  diameter, 
and  then  it  perforates  the  adjacent  cranium.  This  growth,  when 
it  originates  from  the  membranes,,  is  commonly  single,  but  if  it 
appears  there  secondarily,  then  there  may  be  several  growths. 
Unless  the  growth  appears  externally,  it  does  not  soften  or  ulcer- 
ate; it  may  even  undergo  regressive  changes  and  become  smaller 
The  stroma  may  become  invested  with  calcareous  deposits. 


220  MEMBRANES    OF    THE    P.RAIN. 

Tubercle. — Isolated  tubercular  deposit  is  sometimes  found  on 
the  meninges;  there  are  usually  several  found,  and  such  growth 
may  reach  the  volume  of  a  cherry.  When  there  are  many,  they 
are  small  in  size.  As  an  exceptional  case,  the  growth  sometimes, 
through  the  fusion  of  several  separate  masses,  has  become  as 
large  as  an  egg.  The  tubercular  growth  is  yellow,  with  a  tinge 
of  green.  The  content  is  caseous  in  character.  If  such  a  growth 
be  split  open,  the  central  portion  will  be  found  hard,  opaque,  and 
dryer  than  the  cortical  portion;  the  latter  is  semi-transparent, 
and  is  traversed  by  reddish  lines,  the  remnants  of  vessels.  And 
thus  this  tubercular  growth  can  be  distinguished  from  the  sar- 
comatous growth,  in  which  vessels  enter  and  remain  permeable. 
Wagner  wisely  remarks  that  the  tubercular  growth  may  be  con- 
founded with  the  syphiloma,  since  the  two,  when  they  have 
undergone  the  caseous  degeneration,  are  quite  similar. 

Si/pJiUoma. — This  product  of  syphilis,  commonly  named  the 
gummy  growth,  can  appear  in  diffuse  or  collected  form;  as  a  rule, 
the  gummy  material  presents  itself  as  a  circumscribed,  well- 
defined  tumor.  Its  site  may  be  in  the  meninges  alone,  or  it  may 
be  seated  in  the  cortical  substance  of  the  brain.  This  growth  is 
never  encysted,  but,  at  its  limiting  boundaries,  it  passes  insensibly 
into  the  parts  around.  Though  it  may  attain  some  dimensions, 
it  never  reaches  the  colossal  volume  which  it  does  in  the  lungs 
and  liver,  in  which  the  gummy  tumor  can  become  as  large  as  an 
orange. 

When  examined  microscopically,  the  syphiloma  is  found  com- 
posed of  cells  and  nuclei;  the  cells  lie  centrally,  wliile  the  nuclei 
occupy  the  peripheral  portion  of  the  tumor.  The  cells  are 
similar  to  those  of  the  white  blood  corpuscles,  with  a  single 
nucleus;  and  these  are  imbedded  in  a  network  of  connective  tissue, 
so  that  the  whole  presents  an  areolar  structure  with  cells  filling 
the  interspaces.  At  a  late  stage  the  cells  and  nuclei  undergo  a 
fatty  change,  similar  to  that  of  many  neoplasms. 

Tlie  Effects  of  Meningeal  Tumors. — The  meningeal  tumors  have, 
as  common  effect,  encroachment  upon,  and  reduction  of,  the  intra- 
cranial cavity,  and  from  such  encroachment  they  produce  dis- 
turbances, which  can  be  placed  under  two  heads:  atropliy  and 
turgescence  of  the  neighboring  tissues.  The  result  of  atrophy  of 
the  structure  of  the  brain  is  to  compensate,  in  some  degree,  the 
encroachment  of  the  enlarging  growth.  The  other  effect  of  the 
meningeal  tumor,  viz.,  turgescence  of  the  parts  impinged  on,  adds 
to  the  trouble,  and  this  may  be  present  in  different  forms;  for 


TREATMENT    OF    MENINGEAL    TUMORS.  221 

example,  the  growth  may  cause  inflammation,  congestion,  oedema 
or  hemorrhage,  in  the  contiguous  parts.  The  effect  of  the 
inflammation,  even  though  it  be  mild,  is  to  cause  softening  of 
the  part  acted  on.  The  effect  of  oedema  and  congestion  is  vari- 
able, as  the  conditions  themselves  are  variable;  and  hence  the 
clinical  symptoms  must  be  variable.  Hydrocephalus,  and  oblit- 
eration of  the  encephalic  veins  and  sinuses,  can  result  from  such 
tumor.  The  nature  of  the  tumor  has  a  strong  bearing  on  the 
condition  of  the  adjacent  structures;  for  example,  certain  growths 
are  inert,  and  act  passively  through  encroachment  and  compres- 
sion; such,  as  a  rule,  are  the  accidental  tumors.  Other  tumors 
are  active  in  their  efforts,  such,  for  instance,  as  cancer;  these 
modify  deeply,  and  often  fatall}^,  the  tissues  which  surround  them. 
Tumors  which  compress  the  cranial  nerves  induce  in  these  a 
fatty  degeneration  which  often  extends  to  the  peripheral  branches 
of  the  nerves.  The  results  of  such  compression  are  easily  seen 
and  estimated  by  the  ophthalmoscope,  when  the  optic  nerve  is 
compressed. 

Treatment  of  the  Meningeal  Tumors. — A  few  of  these  tumors 
may  be  treated  by  internal  medication;  especially,  one  may  hope 
to  do  something  in  this  way  in  case  the  growth  is  of  syphilitic 
origin.  When  concomitant  syphilitic  disease  is  present  justifying 
the  diagnosis  of  syphiloma  in  the  meninges,  then  the  patient 
should  be  subjected  to  a  thorough  course  of  antisyphilitic  reme- 
dies; for  a  month,  at  least,  he  should  take  the  protiodide  of 
mercury  in  doses  of  a  half  grain,  three  times  a  day.  When  this 
has  been  done,  the  iodide  of  potassium  should  be  given  and  con- 
tinued for  some  montlis.  In  this  way  grave  subjective  phenomena 
have  been  caused  to  disappear,  within  the  author's  observation; 
perversion  of  mental  energy  and  motor  function  has  been  caused 
to  disappear,  and  the  seemingly  hopeless  invalid,  within  four 
months,  has  been  restored  to  health.  Even  in  case  the  tumor  be 
carcinoma  or  sarcoma,  the  well-proven  properties  of  iodine  and 
mercury  to  disintegrate  tissue,  justify  and  encourage  their  employ- 
ment, certainly  for  a  period  of  six  or  eight  weeks. 

But  where  inward  medication  fails,  or  has  no  indication  for 
its  use,  then  the  question  of  surgical  interference  arises.  The 
experience  of  modern  times  justifies  or  permits  work  upon 
ground  which  was  once  forbidden;  and  especially  is  this  true  of 
the  interior  of  the  head,  where  surgical  daring,  Prometheus-like, 
has  scaled  the  hitherto  untrodden  heights  and  brought  thence 
to  man  the  empyrean  boon  of  relief  of  disease,  which  heretofore 


222  MEMHUANKS    OF    THE    liKAIX. 

seemed  securely  and  iini)regnably  entrenched  within  the  cranial 
walls.  It  is  well  that  this  adventurous  daring  shouhl  not  arouse 
a  cohort  of  greater  ills,  wiiich  sometimes  do  follow  the  returning 
steps  of  the  bold  surgeon. 

As  said,  iu  a  few  cases  of  meningeal  tumor,  surgical  interven- 
tion is  proper.  Namely,  the  trephine  may  be  used,  and  through 
an  opening  in  the  skull  the  neoplasm  may  be  sought  for,  and 
if  found  it  can  then  be  extracted  and  the  patient  thus  given  an 
opportunity  of  recovery.  Trephination  should  only  be  resorted 
to  in  those  casesin  which  the  diagnostic  signs indicateconclusively, 
or  with  probability,  tlie  site  of  the  neoplasm;  and  an  additional  con- 
dition must  necessarily  be  that  this  site  is  accessible  and  can  be 
opened  without  wounding  vessels  or  veins  which  traverse  the 
wall.  As  trustworthy  indications  of  the  existence  of  a  growth 
would  first  be  a  continuous  pain  at  one  point  of  the  liead;  and, 
secondly,  perverted  sensation  and  motion  located  peripherally,  if 
their  anatomical  channels  converged  to  tlie  same  .source,  might 
almost  conclusively  denote  the  location  of  the  tumor.  How 
much  relief  might  be  obtained  would  depend  on  the  nature  of 
the  tumor;  if  it  should  fortunately  prove  to  be  a  fibroma,  a 
lipoma,  a  tuberculous  mass,  or  a  calcareous  concretion,  then  one 
might  expect  that  permanent  recovery  might  follow  the  removal. 
But,  on  the  contrary,  if  the  growth  were  of  a  malignant  nature, 
as  sarcoma  or  a  carcinoma,  then  the  operation  could  only  be  fol- 
lowed by  failure.  But  even  in  this  unfortunate  condition,  the 
impossibility  of  making  matters  worse  would  grant  unusual 
liberty  to  the  surgeon.  The  surgeon  and  physician  sometimes 
meet  cases  in  which  life  is  a  burden  and  death  a  favor  to  the 
unfortunate  subject ;  examples  of  such  are  incurable  diseases 
which  are  coupled  with  continuous  pain  and  a  perversion  of  the 
functions  of  one  or  more  of  the  organs  through  which  life  is 
maintained;  and  under  this  head  no  more  apposite  example  can 
be  cited  than  the  intracranial  growth,  which  by  its  volume  inter- 
feres with  the  office  of  the  brain. 

.Justified  by  the  diagnosis  of  such  conditions,  the  trephine 
should  be  applied  over  the  probable  location  of  the  growth,  and 
an  ample  section  be  uplifted.  As  soon  as  the  dura  mater  has 
been  ojtened  to  view,  its  color,  tension,  and  upheaval  would  indi- 
cate whether  there  were  a  neoplasm  underneath;  or  if  the  tumor 
had  perforated  the  meninges,  it  would  at  once  be  evident  to  the 
eye.  If  the  tumor  were  concealed,  those  membranes  must  be 
opened  and  the  neoplasm  enucleated,  or  excised  from  the  parts 


CONCUSSION    OF    THE    BRAIN.  223 

with  which  it  is  connected;  that  is,  the  work  of  removal  will  be 
done  as  the  conditions  suggest  or  permit.  Stereotyped  rules  for 
guidance  in  such  operative  procedures  cannot  be  formulated; 
ordinary  mechanical  ability  best  finds  a  method  for  itself.  Inas- 
much as  in  such  operations  the  integrity  of  the  parts  must 
sometimes  be  disturbed  greatly,  hence  immediate  closure  would 
rarely  be  advisable.  After  the  tumor  has  been  removed,  the 
torn  shreds  or  ragged  edges  of  the  membranes  must  be  cut  off, 
and  the  wound  cleansed  antiseptically,  sprinkled  with  iodoform 
and  then,  a  drainage  tube  being  properly  placed,  the  external 
Avound  can  be  closed  by  suture,  except  at  the  point  where  the 
drain  lies. 

The  structure  next  in  order,  as  we  pass  from  above  downwards, 
is  the  brain,  of  which  the  affections  falling  within  the  domain  of 
surgery  will  now  be  considered. 

Concussion  of  the  Brain. — During  tlie  last  fifty  years  the  sub- 
ject of  concussion,  or  commotion,  as  the  Germans  and  derivative 
Latin  writers  term  it,  has  been  the  matter  of  careful  study,  obser- 
vation and  experimental  research.  It  is  caused  by  some  external 
violence  which  communicates  vibration,  oscillation  or  minute 
movement  to  the  anatomical  elements  of  the  parts  acted  on.  In  the 
causation  all  observers  agree ;  but  what  occurs  in  the  constituent 
elements  of  the  parts  affected  cannot  be  said  to  be  as  yet  satisfac- 
torily settled.  All  parts  of  the  body  may  be  the  subject  of  such 
action:  bones,  muscles,  nerves,  viscera;  and  some  assert  that  the 
blood  itself  may  be  the  subject  of  concussion.  The  study  of  the 
effects  of  concussion  has  been  devoted  chiefly  to  the  brain  ;  yet  it 
seems  certain  that  the  same  cause  would  be  followed  by  like  effects, 
no  diff'erence  Avhat  part  of  the  body  should  be  the  site,  and  hence 
that  one  common  definition  might  be  given  of  concussion  founded 
on  physical  and  physiological  laws.  In  a  classic  article  on  this 
subject  by  Verneuil  the  able  French  surgeon  and  writer,  after 
revealing  to  the  reader  the  difficulties  which  perplexed  him  in 
his  task,  Verneuil  offers  us  the  following  definition  of  concus- 
sion:  "It  is  a  series  of  phenomena  occurring  more  or  less 
suddenly  which  result  from  a  mechanical  shaking  (jarring  move- 
ment) of  the  anatomical  elements,  tissues  and  organs,  character- 
ized by  a  temporary  excitation  or  depression  of  the  properties, 
offices  or  uses  of  the  parts  which  are  shaken;  and  as  a  result  there 
are  caused  anatomical  changes  similar  to  those  which  are  nor- 
mally seen  in  the  successive  phases  of  functional  activity  and 
functional  repose."     This  definition  is  the  embodiment  of  what 


22^  THE    IJJIAIX. 

its  author  has  derived  from  his  own  observation  and  that  of 
others;  and  especially  from  tlie  results  which  others  have  obtained 
in  experiments  on  animals. 

In  the  milder  grades  of  concussion  in  the  animal,  the  question 
has  been  whether  there  is  any  appreciable  lesion  to  be  discerned 
in  tiie  part  subjected  to  experiment;  the  most  admit  that  such 
lesion  cannot  be  discovered;  and  since  in  man,  in  case  of  concus- 
sion of  the  brain,  tlie  subject  soon  recovers,  hence  there  is  no 
opportunity  of  searching  for  the  evidence  of  such  lesion.  For,  as 
Verneuil  savs,  we  derive  our  elements  of  the  diagnosis  of  anv 
disease  from  three  sources :  to  wit,  the  causation,  the  symptoms 
arising,  and  thirdly  from  the  direct  inspection  of  the  part  affected. 
But  in  case  of  cerebral  concussion  one  or  more  of  these  sources  of 
information  is  often  wanting.  The  inspection  of  the  injured  part 
is  wholly  denied  to  the  surgeon;  the  extent  of  the  violence  done 
can  often  only  be  vaguely  and  imperfectly  estimated;  and  not 
unfrequently  it  is  wholly  unknown,  as  where  the  patient  is  found 
unconscious  or  unable  to  explain  how  he  was  injured;  and  finally 
the  remaining  source  of  knowledge,  viz.,  the  symptoms,  are  often 
far  from  being  clear  and  well  defined. 

Concussion,  as  wall  presently  be  more  fully  detailed,  may  be 
said  to  present  itself  in  three  grades,  wdiich  we  will  designate  the 
mild,  severe  and  fatal.  The  second,  which  offers  symptoms 
sufficiently  durable  to  admit  of  deliberate  consideration,  presents 
as  marked  condition  a  depression  of  the  cardio-pulmonary  func- 
tions, in  which  pulse  and  breathing  are  slow  and  feeble;  temper- 
ature is  lowered  as  a  result  of  the  preceding;  the  functions  of  the 
sensory  and  motor  nerves  are  temporarily  aljolished;  the  patient 
neither  moves  nor  feels.  The  mental  faculty  is,  for  a  time, 
reduced  to  a  nullity;  the  patient  is  not  conscious  of  existence,  and 
in  all  this  the  animal  for  a  time  has  lost  his  distinguishing 
characteristic,  and  lies  at  the  verge  of  plant  life. 

Many  explanations  of  these  conditions  have  been  offered,  as 
will  be  seen  from  a  brief  review  of  the  literature  which  during 
the  last  fifty  years  has  been  written  on  the  matter. 

In  1842  Haworth  wrote  on  concussion  of  the  brain,  and 
claimed  that  the  violence  impinging  on  one  side  of  the  skull  car- 
ried the  brain  against  the  opj^osite  wall,  and  thence,  rebounding, 
a  vacuum  succeeded,  in  which  blood  and  gas  collected,  the  phe- 
nomena being  similar  to  those  of  contre-coup.  Haworth  thinks 
that  a  vacuum  is  also  formed  in  the  brain  in  those  who  ascend 
great  heights,  and  thus  he  would  explain  the  cerebral  trouble 


CONCUSSION    OF    THE    BEAIX.  .  225 

sometimes  present  in  such  cases,  Tliis  explanation  of  the  phe- 
nomena arising  from  concussion  could  only  be  applicable  in  those 
cases  which  had  arisen  from  great  violence,  in  which  the  patient 
dies  at  once  from  the  violence  done  to  the  brain;  and  in  such 
cases  the  organ  is  lessened  in  its  volume,  and  into  the  empty 
space  thence  arising,  blood  escapes  from  the  lacerated  vessels. 
The  filling  of  the  space  with  blood  is  therefore  a  secondary  effect 
of  the  injury. 

In  1852  there  were  reports  on  concussion  of  the  brain  by 
Fano,  Chassaignac  and  Haas;  the  former  two  find  that  where 
death  has  immediately  followed  a  blow  on  the  head,  then  there 
will  be  found  effusion  of  blood  around  the  pons  Varolii;  but  if 
death  occurs  later,  then  in  the  cerebral  structure  there  will  be 
found  disseminated  small  clots  of  blood,  which  these  writers 
attribute  to  cerebral  contusion.  Fano  and  Chassaignac  deny 
that  concussion  can  injure  without  leaving  some  signs  of  violence: 
one  always  can  find  egchymosis,  or  marks  of  cerebral  injury. 
Haas,  however,  thinks  that  there  can  be  concussion  with  or  with- 
out ecchymosis.  In  each  there  is  sopor  with  unconsciousness. 
If  it  be  simple  concussion,  then  these  conditions  may  soon  dis- 
appear, but  if  blood  be  effused,  then  these  symptons  may  con- 
tinue and  even  increase  in  intensity. 

Continuing  his  studies  in  1853,  Fano  combats  the  notion  that 
in  concussion  there  is  no  perceptible  material  change  in  the 
cerebral  structure;  but  he  claims  that  there  will  be  found  effusion 
of  blood  near  the  base  of  the  brain.  Fano,  Chassaignac  and 
Lawson  have  found  in  the  brain  small  points  of  effused  blood, 
not  larger  than  millet  seeds.  In  mild  cases,  Eisenmann  thinks 
there  is  a  shock  which  acts  reflexively  through  the  vaso-motor 
filaments  on  the  capillaries,  and  produces  a  stasis  of  blood  in  the 
latter.  And  in  more  severe  cases  the  stasis  may  be  carried  to 
the  extent  of  rupturing  the  vessels.  The  order  of  the  phenom- 
ena is  as  follows:  The  shock  is  first  propagated  from  the  vibrating 
bones  to  the  nerves,  and  thence  a  recurrent,  reflex  action  in  and 
through  the  nerves;  next  stasis,  and  sometimes  rupture  of  the 
vessels,  and  occasionally  structural  softening. 

Paget,  writing  on  cerebral  concussion  in  1863,  made  three 
stages  of  it.  In  the  first  stage  unconsciousness  occurs,  and  this 
may  vanish,  and  the  patient  recover.  In  the  third  stage  the 
violence  is  greater,  and  the  condition  may  be  sthenic  or  asthenic 
in  character.  The  asthenic  symptoms  occur  early,  viz.,  within  a 
day  or  two.     The  sthenic  symptoms  occur  after  a  longer  period, 


22(>  THE  iniAix. 

viz.,  after  ten  or  eleven  days.  Between  the  first  and  third,  or 
inflammatory  stage,  Paget  2)hices  a  second  one,  in  which  there 
is  ahnost  a  total  absence  of  morbid  signs.  After  surgical  opera- 
tions, for  example,  an  amputation,  Paget  finds  that  similar  condi^ 
tions  may  arise,  viz.,  one  of  excitement  and  one  of  depression. 
Paget  estmates  the  chances  of  recovery  to  be  very  slight  after 
severe  concussion  of  the  brain.  In  such  cases  not  jnoro  than  one 
in  twenty  got  well. 

Alquie,  in  Paris,  made  some  experiments  in  1805  on  concus- 
sion, and  concludes  from  them  that  tlirough  the  injury  caused, 
the  functions  of  the  brain  are  more  or  loss  interfered  with,  and, 
further,  he  believes  that  concussion  and  contusion  do  not  differ 
much  from  each  other  in  their  respective  actions.  The  lesion 
produced  by  slight  concussion  is  so  slight  that  it  eludes  the  closest 
search  with  the  eye.  Its  mechanism  is  not  that  of  vibration,  but 
of  a  blow  that  came  and  vveut  at  once.  The  causal  violence  carries 
the  brain  forwards  in  (xne  direction,  viz.,  that  of  the  causal  violence. 
Alqui^  concludes  that  concussion  "and  contusion  are  convertible 
terms.  Local  and  diffused  concussion  cannot  be  distinguished 
from  each  other  in  their  action.  The  phenomena  resulting  from 
severe  concussion  are  vertigo,  fainting,  weakness,  drowsiness,  and 
coma.  The  cerebral  trouble  caused  may  apj^ear  in  remissions 
and  exacerbation.  From  concussion  one  or  many  functions  of 
the  head,  or  parts  dependent  on  it,  may  be  impaired  or  annulled, 
and  this  disturbance  may  be  brief  or  long  lasting.  Concussion 
in  its  action  resembles  grave  mental  disease. 

In  his  treatment  Alquie'  is  in  accord  with  Paget.  Collapse 
and  depression  demand  stimulants;  active  reaction  denjands 
an  opposite  course. 

Beck,  of  Freiburg,  in  1865,  referred  the  effects  of  cerebral  con- 
cussion to  violence  transmitted  to  the  medulla  oblongata,  and  to 
lesion  of  thecentres  which  preside  over  the  functions  of  the  heart 
and  lungs.  Pie  finds  as  common  causal  agency  a  blow  with  a 
blunt  instrument. 

Witkowsky,  in  1877,  made  some  experiments  on  animals,  in 
which  the  head  was  struck  with  a  hammer,  and  the  pressure  of 
the  blood  in  the  carotid  arteries  was  noted  in  the  meantime. 
The  immediate  effect  was  increase  of  blood  pressure  in  these  ves- 
sels. The  increase  commenced  immediately  after  the  injury,  and 
reached  its  highest  degree  in  from  twenty  to  fifty  seconds,  and 
continued  for  from  one  to  two  minutes.  This  increased  pressure 
followed  both  slight  and  more  severe  concussion.     It  was  after- 


CONCUSSIOX    OF    THE    BRAIN.  227 

wards  succeeded  by  a  slight  descent  of  pressure  below  the  normal 
st^lndard.     The  pulse,  as  a  rule,  was  not  changed. 

In  cases  in  which  the  skull  had.  been  trephined  so  that  the 
brain  could  be  seen  after  removing  sections  of  the  dura  mater, 
it  was  found  that  the  strokes  caused  a  perceptible  contraction  of 
the  vessels  of  the  dura  mater.  This  continued  for  a  moment  or 
two,  and  then  a  slight  reaction  followed.  Witkowsky  decided 
that  those  alterations  in  the  blood  pressure  were  not  due  to  the 
oscillations  from  concussion,  but  were  the  consequences  of  direct 
action  on  the  nerve  matter.  Though  Witkowsky  offers  this  state- 
ment designed  to  explain  the  conditions  present,  yet  it  is  proba- 
ble that  few  readers  can  comprehend  it. 

Duret,  of  Paris,  in  1877,  made  experiments  on  animals,  in 
which  he  studied  the  effects  of  concussion  on  the  brain.  The 
violence  done  to  heads  of  animals  was  produced  by  blows  on  the 
skull  and  also  by  violently  injecting  fluid  into  the  cranial  cavity 
through  a  trephined  opening.  He,  finds  the  leading  results  of 
concussion  to  be  slowness  of  the  pulse  and  respiration;  and,  find- 
ing au  absence  of  all  lesion  in  the  cerebral  liemispheres,  he  sought 
for  injury  in  the  medulla  oblongata.  In  the  experiment  in 
which  water  was  violently  injected  into  the  skull,  the  fluid  in 
the  lateral  ventricles  was  caused  to  pass  downwards  through 
the  middle  ventricle  and  the  canal  of  Sylvius  to  the  fourth 
ventricle.  In  its  passage  through  the  canal,  the  fluid  caused 
laceration  of  the  walls  of  the  narrow  passage.  In  another  exper- 
iment the  skull  was  trephined  above,  and  the  posterier  ligament 
connecting  the  axis  and  atlas  was  exposed  when  pressure  was 
made  through  the  trephined  opening  above;  then  an  impulse 
could  be  perceived  below  from  the  descent  of  the  fluid  into  the 
spinal  canal. 

Direct  experiments  were  done  chiefly  by  the  injection  of  water 
into  the  cranial  cavity.  This  fluid  was  forcibly  thrown  against 
the  surface  of  the  brain  beneath  the  dura  mater.  It  is  evident 
that  the  action  of  such  violence  differs  from  that  caused  by  a 
blow.  It  is  not  so  instantaneous,  the  violence  progressing  from  a 
slight  grade  to  a  higher  one  ;  and  only  when  the  fluid  reaches  a 
certain  amount  could  it  displace  the  intra-ventricular  fluid. 
Such  action  must  differ  from  that  in  which  the  violence  impinges 
on  the  outside  of  the  skull,  and  thence  travels  onwards  to  the 
less  resistant  cerebral  matter.  Hence  the  results  of  Duret's  exper- 
iments may  be  deemed  rather  an  approximation  to,  than  an 
actual  reproduction  of,  the  action  of  concussion  from  direct 
violence. 


228  THE    KRAIX. 

Ill  1878  Duret  continued  his  researches  on  this  subject,  and 
divides  the  shock  of  concussion  into  three  classes,  viz  ,  central, 
bulbar  and  medullary,  according  as  one  of  these  structures  is 
most  involved.  In  the  case  of  a  blow,  the  passage  of  the  fluid 
downward  acts  most  severely  on  the  bulb. 

Duret  divides  the  action  of  concussion  into  two  periods;  in  the 
first  period  there  is  a  spasmodic  and  a  paralytic  stage,  in  which 
there  are  coma  and  depression.  In  the  second  period,  there  are 
congestion  and  inflammation.  The  site  of  the  blow  has  an  influ- 
ence on  the  morbid  phenomena;  for  when  the  forehead  receives 
the  blow,  the  pons  and  bulb  are  the  most  affected;  but  when  the 
side  of  the  head  is  the  site  of  the  violence,  then  the  other  hemis- 
phere is  more  affected. 

After  this  review  of  the  subject  of  concussion,  if  the  facts  which 
have  been  drawn  from  so  many  quarters  be  condensed  and  con- 
clusions be  drawn  from  them,  the  following  may  be  offered  as  an 
epitomized  summary  of  the  changes  which  are  induced  tempora- 
rily or  continuously  in  the  brain  from  concussion.  In  the  mildest 
grade  there  is  a  brief  diminution  of  the  blood  pressure  in  the  part; 
its  tension  is  temporarily  lowered.  As  the  result  of  this  there  is 
mental  disturbance;  the  cells  and  the  cortex  of  the  brain,  on  whose 
normal  condition  the  evolution  of  thought  in  some  unknown  way 
depends,  are  deprived,  for  a  few  moments,  of  their  accustomed 
supply  of  nutrient  material;  the  result  is  a  brief  perversion  of 
intellect;  memory  is  lost;  the  power  to  recognize  surrounding 
objects  is  weakened  or  lost.  As  a  personal  illustration  of  this, 
from  a  fall  from  a  carriage,  the  author  once  suffered  temporary 
concussion  of  the  brain;  though  he  arose  at  once  to  his  feet,  on  a 
street  with  which  he  was  very  familiar,  yet,  for  a  minute,  all 
appeared  to  him  as  if  he  were  in  a  strange  city,  and  that  picture 
registered  on  memory  ^^et  remains  as  an  enduring  scene  of  mental 
imagery.  And  though  there  was  knowledge  of  what  had  occurred, 
and  thought  enough  to  search  the  head  for  fracture,  yet  the 
subject  of  the  injury  possessed  no  accurate  knowledge  of  his  sur- 
roundings. The  author  would  attribute  those  conditions  to  a 
temporar}'  disturbance  of  the  circulation  on  the  surface  of  the 
brain. 

If  the  violence  be  somewhat  greater  than  that  here  supposed, 
then,  to  the  disturbance  of  blood  pressure,  there  is  superadded  a 
disturbance  of  the  cellular  constituents  composing  the  surface  of 
the  brain.  A  jostling  or  dis])lacement  of  the  molecular  elements 
of  those  cells,  even  though  it  be  microscopically  minute,  must 


CONCUSSION    OF    THE    BRAIN.  229 

suffice  to  induce  functional  derangement.  In  such  condition  the 
patient  lies  unconscious  to  all  that  is  around  him;  lie  breathes 
naturally;  the  pulse  is  commonly  somewhat  weakened  and  regu- 
lar; the  temperature  is  not  increased,  and  sometimes  is  less  than 
normal;  the  pupil  is  neither  dilated  nor  contracted,  and  reacts 
somewhat  to  light.  The  patient  may  remain  for  hours,  a  day,  or 
even  a  week  in  this  condition,  in  which  he  is  neither  awake  nor 
asleep;  he  is  so  nearly  asleep  that  his  condition  is  often  taken  for 
sleep.  But  it  differs  from  sleep  in  tliis  that  the  eyeballs  do  not 
occup}^  the  upturned  divergent  position  they  have  in  healthy  sleep; 
they  are  often  in  motion  beneath  the  closed  lids.  There  is  an 
absence  of  snoring  in  the  breathing;  in  fact,  the  patient  breathes 
as  one  who  is  partl}^  asleep,  rather  than  as  one  who  is  really  so. 
For  the  Jack  of  a  name,  we  will  designate  it  the  sleep  of  concus- 
sion. 

In  the  grades  of  concussion  just  mentioned,  its  action  is  chiefly 
manifested  in  obtundingor  temporarily  suspending  the  functions 
oftliemind;  but  if  the  intensity  of  the  causal  violence  be  still 
greater,  then,  besides  the  abolition  of  the  thinking  faculty,  the 
cardio-pulmonary  functions  are  disturbed,  dependent,  doubtless, 
on  lesion  of  the  centres  at  the  base  of  the  brain,  wdiicli  preside 
over  these  functions;  lesions  which  were  represented  by  the 
lacerations  in  that  region  observed  by  Duret.  The  pulse  is  soft 
and  often  irregularly  hastened.  The  breathing  is  similarly 
affected;  regular  may  alternate  with  irregular  breathing,  and  so 
may  slowness  with  acceleration.  And  these  disturbances  of  the 
actions  of  the  heart  and  lungs  conjoined  to  unconsciousness,  may 
remain  for  days  and  even  weeks,  and.  then  consciousness  may 
reappear  suddenly,  the  patient  arousing,  as  from  a  sleep,  wath  a 
gradual  disappearance  of  the  other  abnormal  conditions.  Such 
an  injury  of  the  head  as  here  described  often  results  from  a  fall, 
from  a  carriage  or  horse;  it  sometimes  occurs  in  accidents 
from  climbing.  In  such  accidents  the  weight  of  the  body, 
multiplied  by  the  velocity  acquired  at  the  final  moment  of  strik- 
ing the  ground,  represents  a  high  degree  of  violence,  especially 
where  the  surface  fallen  on  is  a  hard  one.  In  such  cases,  when 
severe,  there  is  a  contusion  of  a  limited  surface  of  the  brain,  and 
thence  results  localized  or  isolated  palsy  of  some  part  of  the  body. 
Or,  as  the  author  has  observed,  there  may  be  partial  hemiplegia 
of  the  arm  and  leg,  and  not  unfrequently  one  limb  is  more 
affected  than  the  other.  And,  at  the  same  time,  there  may  be 
restlessness  of  the  limbs  on  the  unparalyzed  side. 


230  THE    BR  A IX. 

Ill  a  still  higher  grade  of  concussion,  the  functions  of  life  are 
permanently  suspended,  either  at  once,  or  death  ensues  in  a  few 
minutes  after  the  receipt  of  the  violence.  Such  fatal  result  has 
given  the  opportunity  of  necropsy,  in  which  the  condition  of  the 
brain  could  be  suspected.  Yet,  singularly  enough,  there  is  far 
from  agreement  among  observers  in  respect  to  these  conditions, 
.some  asserting  that  the  brain  did  not  fill  the  skull;  others  have 
found  the  contrary  state.  Of  the  first  condition  there  is  a  notable 
instance  on  record,  an  observation  made  and  reported  b}'  Littre 
over  a  century  ago.  This  case,  cited  by  nearly  all  writers  on  con- 
cussion, was  that  of  a  criminal,  who,  to  escape  punishment,  ran 
and  struck  his  head  so  violenth'  against  the  wall  of  his  prison  that 
he  fell  dead.  The  desperate  energy  displayed  in  the  fatal  act  has 
had  no  small  share  in  retaining  the  fact  in  history.  ,  In  the 
necroj)sy  of  the  case  reported  by  Littre,  the  cerebral  matter  was 
found  broken  down,  and  to  lack  much  of  filling  the  cranial  cavity; 
that  is,  a  vacuum  was  found  in  the  upper  part  of  the  skull.  There 
have  been  reported  a  few  other  cases  in  which  there  was  found  a 
slight  open  space  above  the  brain,  in  those  who  have  died  from 
cerebral  concussion.  There  has*  been  reported  an  effacement  of 
the  natural  irregularities  of  the  cortex  of  the  brain.  However, 
other  observers  contend  that  both  the  empty  space  as  well  as  the 
alleged  leveling  of  surface,  is  not  present  in  the  unopened  cranium, 
but  is  caused  by  the  escape  of  blood  from  vessels  which  are 
divided  in  opening  the  cranial  cavit^^  Notwithstanding  these 
discordant  utterances,  the  predominant  weight  of  observation  is 
on  the  side  of  those  who  assert  that  there  is  some  lessening  of 
volume  as  well  as  effacement  of  the  cortical  irregularities  of  the 
brain.  Besides  these  evidences  of  violence,  the  cerebral  matter 
on  being  cut  presents  minute  ecchymoses  of  blood,  due  to  rupture 
of  minute  vessels.  And  it  is  probable  that  such  rupture,  in  less 
extent,  occurs  in  concussion  of  a  milder  grade. 

Diagnosis. — Tlie  diagnosis  of  cerebral  concussion  is  an  easy 
matter  in  cases  in  which  there  is  a  history  of  violence  acting  on 
the  head.  Yet,  in  the  absence  of  such  history,  the  problem  of 
diagnosis  becomes,  sometimes,  difficult,  since  it  must  be  wholly 
solved  by  the  symptoms  present;  then  the  pulse,  breathing,  pupil, 
and  color  of  the  face  give  valuable  information ;  stertor  and 
narrowed  pupil  point  to  poisoning  with  opium;  the  fumes  of 
spirits  in  the  breath  point  to  alcoholic  excess.  An  instance  of 
the  latter  kind  came  under  the  notice  of  the  author:  a  man  who 
was  found  prostrate  by  the  side  of  the  street  was  the  object  of 


CONCUSSION    OF    THE    BRAIN.  231 

puzzling  study  to  soine  physicians,  when  the  coachman  of  one  of 
the  doctors  solved  the  matter  by  saying  that  he  would  give  a  half 
dollar  to  be  as  sick  as  the  man  was. 

There  are  cases  in  which  the  work  of  diagnosis  is  much  embar- 
rassed b}^  the  lesion  not  being  a  simple  one  of  concussion;  there 
may  be  conjoined  to  it  contusion  and  compression,  especially 
compression,  which  would  greatly  modify  or  change  the  usual 
symptoms  of  a  case  of  concussion;  in  fact,  concussion  and  com- 
pression present  in  a  case  would  naturally  interact  and  influence 
the  symptorns  of  each  other;  and  in  such  case  the  surgeon  would 
find  it  extremely  difficult,  perhaps  impossible,  to  determine  all 
the  conditions  present;  in  such  embarrassment,  the  most  promi- 
nent symptom  should  receive  attention  and  indicate  the  proper 
treatment.  In  the  following  chapter  devoted  to  the  consideration 
of  compression  of  the  brain,  there  will  be  presented  the  symptoms 
by  which  concussion  and  compression  of  the  brain  may  be  dif- 
ferentiated. 

Prognosis. — From  what  has  preceded,  it  is  clear  that  the  prog- 
nosis of  concussion  of  the  brain  must  depend  on  the  grade  of  the 
injur}'.  In  the  grades  of  slight  severity  a  recovery  may  certainly 
be  anticipated  at  an  early  period.  But  in  the  severe  forms  the 
prospect  is  more  unfavorable;  the  patient  may  remain  in  an 
unconscious,  half-dead  state  for  weeks,  and  afterward  slowly 
recover;  or  from  his  half-dead  condition  he  may  lapse  into  actual 
death.  Also  it  is  to  be  observed  that  after  some  concussion, 
though  the  patient  may  live,  yet  not  unfrequently  there  remains 
some  vestige  or  memento  of  the  injury  in  the  form  of  perverted 
motion,  sensation  or  impaired  mentality.  From  the  observation 
of  Griesinger  and  other  alienists  it  has  been  found  that  the  men- 
tal character  often  undergoes  some  change  in  those  who  have 
been  the  subjects  of  severe  cerebral  concussion.  The  memory,  as 
has  been  observed  by  the  writer,  may  be  weakened  or  altered  in 
some  way;  the  recollection  of  proper  names,  of  specific  nouns 
and  adjectives  may  be  partly  or  wholly  lost;  from  the  framework 
of  language  may  be  plucked  the  most  of  its  exuberant  apjDcndages, 
and  the  whole  be  reduced  to  a  meager  skeleton  of  generic  headings 
and  categories.  Besides  this  the  character  of  the  individual  may 
be  slightly  or  greatly  modified.  The  hitherto  well-controlled 
temper  may  become  vehement  and  rash;  the  patient  has  out- 
bursts of  anger,  and  may  become  the  actor  of  lawless  deeds.  He 
becomes  distrustful  of  those  around  him.  These  changes  may 
be  plainly  manifest,  or  they  may  be  so  slight  as  onl}^  to  be  per- 


232  THE    BRAIX. 

ceptible  to  the  subject's  intimate  friends.  And  whatever  character 
these  changes  may  assume,  they  will  probabl}^  remain  permanent, 
inasmuch  as  they  depend  on  structural  change,  which  will  con- 
tinue unchanged.  In  modern  times  when  crime  seeks  for  its 
defense  that  its  subject  cannot  control  his  action,  and  consequently 
that  he  is  not  responsible  for  liis  offenses,  the  matter  of  concussion 
has  assumed  a  special  importance  in  Forensic  Medicine.  As  the 
concu.ssion  of  the  spinal  column  from  railway  accident  on  account 
of  real  or  assumed  injury,  seeks  reparation  from  the  pocket  of  the 
owning  corporation,  so  the  transgressor  of  laws  often  claims 
immunity  on  the  ground  that  at  some  time  previously  he  has  been 
injured  in  his  head,  and  as  concussion  leaves  no  tangible  or  visible 
mark,  hence  it  conveniently  serves  the  purpose  of  such  subterfuge 
Treatment  of  Concussion  of  the  Brain. — Since  there  are  two 
totalh'  different  states  in  which  the  patient  of  concussion  may  be, 
namely,  depression  or  excitation,  so  the  treatment  must  be  shapen 
as  one  or  the  other  condition  exists.  As  a  rule,  the  first  effect  of 
concussion  is  to  induce  depression  and  exhaustion  of  the  vital 
forces;  and  this  condition  must  be  met  and  counteracted  by 
stimulants  and  excitants.  The  patient  is  often  so  prostrated  that 
the  reflex  act  of  swallowing  can  only  be  imperfectly  performed, 
a  fact  which  renders  it  difficult  to  administer  remedies  by  the 
mouth.  If,  while  the  muscles  of  deglutition  are  in  a  partly 
palsied  .state,  liquid  medicine  be  given  by  the  mouth,  the  most  of 
it  will  probably  pass  into  the  trachea,  and  add  to  the  patient's 
perilous  condition  by  partly  asph  vxiating  him.  In  fact,  the  same 
precaution  is  required  here  as  must  be  exercised  in  administering 
matters  to  a  person  moribund  or  near  death;  the  wine  or  other 
thing  thus  given,  as  the  writer  has  witnessed,  can  strangle  and 
immediatelj'  end  life.  Hence,  wlien  the  patient  is  greatly  pros- 
trated by  depression,  and  cannot  readily  swallow,  fumes  of 
ammonia  should  be  applied  to  the  nose;  also  tickling  the  nostrils 
will  often  arouse  the  patient.  Stimulants,  as  brandy  and  warm 
w'ater,  and  black  coffee,  may  be  injected  into  the  rectum.  Hot 
applications  should  be  placed  over  the  prrecordia,  and  the  surface 
of  the  body  should  be  well  rubbed  so  as  to  promote  the  move- 
ment of  the  blood.  In  case  of  extreme  prostration,  syncope  may 
be  avoided,  or  rather  life  awakened  by  lowering  the  head  so  that 
the  heart  may  be  aided  by  gravitation  in  carrying  the  blood  to 
the  brain.  After  the  patient  has  been  sufficiently  resuscitated  to 
swallow,  then  remedies  may  be  given  by  the  mouth.  The  admin- 
istration of  stimulants  must  be  limited  to  the  period  of  depression; 


'concussion  of  the  brain.  233 

afterwards  the  treatment  must  look  to  controlling  the  inflamma- 
tory symptoms  which  usually  present  themselves  after  a  few  days; 
the  stage  of  excitement  is  ushered  in  about  the  eighth,  ninth, 
or  tenth  day  after  the  receipt  of  the  injur3\  Should  the  patient 
be  plethoric,  then  bleeding  from  the  arm  should  be  done;  not  less 
than  a  pint  of  blood  should  be  drawn.  The  signal  advantages 
of  such  depletion  have  been  verified  by  the  writer  in  several 
instances.  If  the  subject  be  very  robust,  as  much  as  thirty  ounces 
can  be  safely  withdrawn;  thus  inflammatory  action,  through  the 
absence  of  material  for  its  maintenance,  is  subdued  and  retained 
within  tolerable  limits.  Depletion  might  be  done  by  means  of 
leeching;  yet  withdrawal  of  blood  from  an  open  vein  is  more 
effectual. 

A  valuable  adjuvant  in  this  antiphlogistic  treatment  is  ice, 
which  should  be  applied  to  the  patient's  head  as  soon  as  he 
merges  from  the  primary  stage  of  depression.  The  ice  well 
crushed  should  be  applied  to  the  head  in  an  India  rubber  bag; 
and  this  should  not  be  heavy,  lest  it  cause  sloughing  on  the  sub- 
jacerit  scalp.  The  head  should  be  maintained  in  an  elevated 
position,  so  as  to  favor  the  descent  of  the  blood  through  the  veins 
towards  the  heart.  All  constriction  of  the  neck  should  be 
avoided.  As  a  faithful  ally  in  this  work  of  derivation  of  the 
blood  from  the  head  is  warmth  applied  to  the  lower  extremities; 
for  this,  hot  water  contained  in  bottles  or  a  rubber  sack,  may  be 
used.  As  there  is  danger  of  freezing  the  scalp,  so  there  is  of 
burning  the  feet,  unless  the  warmth  be  carefully  used. 

As  internal  treatment  there  should  be  given  a  purge;  and  for 
this  none  is  better  than  calomel  and  jalap,  ten  grains  of  each. 
Besides  this,  to  restrain  or  prevent  the  development  of  inflamma- 
tion, there  should  be  administered  iodide  of  potassium,  in  doses 
of  ten  grains,  repeated  every  four  hours,  for  the  adult.  If  the 
patient  be  a  child  of  four  or  five  years  of  age,  the  dose  should 
amount  to  three  grains,  repeated  three  or  four  times  daily.  And 
should  there  be  the  usual  restless  somnolence,  this  must  be  con- 
trolled by  bromide  of  potassium,  of  which  an  amount  equal  to 
that  of  the  iodide  of  potassium  should  be  given.  By  the  use  of 
this  internal  medication,  the  author  has  repeatedly  seen  the  sub 
jects  of  severe  concussion  pass  safely  through  the  inflammatory 
stage;  the  temperature  was  retained  in  low  limits. 

There  should   be  mentioned  a  mode  of  treatment  formerly 
much  used  in  cases  of  severe  cerebral  concussion:  this  was  vesi- 
cation of  the  scalp.     To  do  this,  flrst  let  the  hair  be  shaven  off, 
16 


234  THK    BRAIN. 

and  then  the  whole  covered  with  Eiiiphistrum  Cantharidis.  This 
does  not  act  entirely  as  an  ordinary  blister;  only  a  small  amount 
of  serum  is  drawn  out,  but  instead,  there  will  form  a  coating  of 
libro-albuminoid  material  over  the  scalp,  tenacious  and  adherent. 
This  vesication  was  a  iavorite  of  Dupuytren;  and  it  is  claimed 
that  good  results  followed  its  use.  Yet  when  one  considers  the 
slight  anatomical  connection  between  the  scalp  and  tli'.  enceph- 
alon,  it  is  difficult  to  conceive  how  this  external  blister  can  act 
on  the  parts  within  the  cranium. 

Frequently,  two  or  three  months  are  required  for  entire  recov- 
ery of  the  patient  so  that  he  can  resume  his  usual  occupation, 
and  for  a  yet  longer  period,  limitation  in  exercise  of  body  and 
mind  should  be  enjoined. 

Compressiou  of  the  Brain. — By  compression  of  the  brain  is 
meant  an  abnormal  condition  arising  from  pressure  acting  from 
without  inwards  on  the  brain,  or  the  compressive  agency  may  lie 
within  the  organ.  In  the  first  case,  the  force  acting  centripetally 
may  be  caused  by  a  portion  of  the  cranial  wall  being  pressed 
inwards  ;  or  from  blood  that  is  extravasated  between  the  cranial 
wall  and  the  dura  mater,  or  between  the  dura  mater  and  the 
cortex  of  the  brain.  Centripetal  compression  may  also  arise 
from  a  neoplasm  springing  from  the  dura  mater,  skull  wall  or 
scalp,  which  tumor  and  its  development  lessen  the  containing 
cavity  and  crowd  against  the  brain.  A  subdural  abscess  may 
attain  such  dimensions  that  it  can  give  rise  to  compression.  A 
foreign  body  having  entered  the  cranial  cavity,  and  occupying  a 
subdural  position,  may  cause  compression.  Again  compression 
can  arise  from  an  ettusion  of  blood  within  the  brain  ;  from  an 
abscess  located  there;  from  an  intra-cerebral  growth;  from  a 
foreign  body  that  has  penetrated  the  brain;  and  lastly,  a  not 
infrequent  cause  of  compression  is  the  swelling  of  the  brain 
through  congestion  or  inflammatory  action. 

The  encephalic  content  is  constituted  of  cerebral  and  cere- 
bellar matter,  of  nerves,  vessels  and  cerebro-spinal  fluid. 

The  material  comprising  the  cerebrum  and  cerebellum  con- 
sists chiefly  of  water;  the  aqueous  contents  make  up  more  than 
three-fourths  of  the  whole;  in  this  it  resembles  blood,  of  which 
water  forms  nearly  four-fifths;*  thus  intercommunication  and 
interchange  of  organic  elements  are  provided  for  and  happily 
facilitated  A  large  part  of  this  water  is  closely  associated  with 
the  cerebral  and  cerebellar  elements;  a  portion  of  it  is  the  cerebro- 
*Moleschott's  Kreislauf  des  Lebens. 


COIMPRESSION    OF    THE    BRAIN.  235 

spinal  fluid,  which  has  no  connection  with  the  structure  of  the 
brain. 

As  is  w^ell  known,  water  is  incompressible  within  limits  which 
can  be  tolerated  by  organized  beings ;  hence,  a  compressing  force 
acting  on  the  brain  does  its  injury  by  displacement;  the  fluid 
content  is  forced  from  the  organic  structure,  and  the  latter  is 
altered  in  its  position  and  form.  Should  the  compression  come 
on  slowly,  then  the  cerebro-spinal  liquid  will  be  forced  from  the 
cranium,  and  the  encroachilient  be  compensated;  this  happens 
in  cases  in  which  there  is  a  gradual  outpouring  of  blood  from 
the  rupture  of  a  vessel.  But  if  the  compressive  force  in  its 
entirety  acts  instantaneously,  then  the  rapid  retreat  of  the  fluids 
before  the  violence  must  injure  the  fragile  structures  through 
which  the  fluids  are  forced;  and  thus  a  slight  or  grave  lesion 
results,  proportional  to  the  degree  of  violence. 

To  verify  the  effects  of  compression  on  the  brain,  experiments 
have  been  made  on  animals;  this  has  been  done  in  two  ways:  by 
the  injection  of  water  into  the  cranial  cavity,  and  by  directly 
pressing  on  the  brain  when  the  latter  is  exposed  by  trephining. 
The  action  of  pressure  when  made  directly  on  the  brain  has  thus 
been  observed  in  animals;  and  its  effects  on  voluntarj'-  motion, 
respiration,  pulse,  and  the  pupil  of  the  eye  have  been  found  to 
correspond  to  conditions  arising  in  the  human  subject  of  cerebral 
compression.  Some  fallacy,  however,  may  be  mingled  in  these 
deductions  from  vivisection,  since  the  violence  which  causes 
compression  in  man  may  be  associated  with  concussion  and  con- 
tusion of  the  brain. 

The  following  are  the  effects  of  uncomplicated  compression 
as  observed  in  the  animals  experimented  on  by  Leyden,  in  1866. 
The  experiments  w^ere  made  by  first  trephining  the  animal's 
skull,  and  measuring  by  means  of  a  dynamometer  the  amount  of 
pressure  which  was  applied.  By  pressure  of  a  mild  degree,  pain 
was  caused  through  the  action  on  the  dura  mater.  When  greater 
force  was  used,  there  was  produced  a  loss  of  consciousness,  with 
coma;  and,  along  with  these  conditions,  in  some  cases  there  were 
spasmodic  contractions  of  the  muscles;  and  when  the  pressure 
was  still  greater,  epileptiform  convulsions  occurred.  In  all 
grades  of  pressure  the  pupils  were  acted  on;  these  were  widened, 
yet  not  equally  so  on  both  sides.  The  pulse  was  altered  according 
to  the  grade  of  pressure;  in  the  commencement  of  compression, 
the  pulse  was  rendered  slower,  but  as  the  pressure  was  increased, 
the  pulse  suddenly  changed,  and  from  being  slow  it  became 
rapid.     These  changes  were  referred  by  Leyden  to  action  on  the 


230  THE    r.KAlN. 

vagus  nerve.  Respiration  in  the  beginning  was  irregular  and 
sometimes  liurried,  and  later  intermittent;  during  coma  the 
breathing  became  slow  and  stertorous;  and  later  it  became  irreg- 
ular and  intermittent  with  long  pauses.  Vomiting  rarely 
occurred.  Death  was  caused  by  paralysis  of  the  respiratory 
nervous  centre.  The  heart  continued  to  beat  for  some  minutes 
after  the  respiration  had  ceased.  The  action  of  compression  of 
the  animal's  brain  corresponds  closely  to  that  which  has  been 
observed  in  man.  In  the  milder  degrees  of  pressure  there  are 
conditions  perceptible  in  the  human  subject  which  cannot  be 
recognized  in  the  animal ;  for  example,  disturbances  of  the  special 
senses  and  of  the  mind  can  be  noted  in  man. 

In  the  experimental  w^ork  on  the  animal,  conditions  of  exci- 
tation and  depression  were  induced,  and  these  conditions  vary 
according  as  the  compression  is  made  gradually  or  suddenly;  for 
if  made  suddenly  there  is  no  preceding  period  of  excitation,  since 
that  of  depression  is  ushered  in  at  once;  but  if  the  force  is  applied 
slowlv,  then  there  is  an  antecedent  period  of  excitement.  And 
sometimes  the  conditions  of  excitation  and  depression  are  com- 
mingled, since  some  parts  of  the  brain  are  pressed  on  much 
more  than  others.  Pus  slowly  forming  may  first  be  indicated 
by  excitation,  which  is  followed  later  by  depression;  and  the 
same  is  the  case  in  which  a  tumor  slowly  grows,  for  here  obtuse 
intellect,  .somnolence,  palsy  and  finally  coma  and  stertor  apj)ear ; 
3'et  only  at  a  late  period. 

Hutchinson  and  Bryant,  prominent  surgeons  of  London,  have 
written  on  compression  from  observations  of  it  in  surgical  prac- 
tice. Bryant,  in  writing  on  injuries  of  the  brain,  in  18G0,  says 
that  when  symptoms  of  compression  immediately  follow  a  blow 
with  a  blunt  body,  there  is  probably  injury  of  the  base  of  the 
brain  through  contre-coup,  and  this  injury  and  its  effects  cannot 
be  reached  by  the  trephine.  The  trephine,  however,  is  especially 
useful  in  cases  in  which  a  fragment  of  bone  has  been  forced  into 
the  skull  and  caused  compression.  Also,  w^iere  compression  has 
supervened  slowly  afterthe  injury,  it  indicates  rupture  of  a  vessel, 
and  here  if  the  vessel  can  be  reached,  trephining  may  bo  done. 

In  1868  Hutchinson  writing  on  compression,  as  deductions 
from  many  cases  observed  that  compression  is  sometimes 
suspected  where  it  does  not  exist;  and  again  it  may  exist  without 
any  indicative  symptoms.  Compression  can  originate  from  the 
effusion  of  blood  between  the  dura  mater  and  the  skull;  and 
unless   this  is  soon  relieved   by  operating,  death   ensues.     The 


COMPRESSION    OF    THE    BRAIN.  2^7 

cases  here  referred  to  are  those  in  which  some  meningeal  artery- 
is  ruptured;  and  it  may  be  suspected  wliere  the  patient  has 
remained  well  for  a  time  after  the  accident,  and  then  signs  of 
compression  have  suddenly  appeared.  From  an  effusion  of  blood 
on  one  side,  the  pupil  of  the  eye  on  the  same  side  is  widened;  and 
meantime  on  the  opposite  side  of  the  body  the  arm  and  the  leg 
can  be  palsied.  Compression  can  occur  from  injury  of  the  cere- 
bral structure;  the  blood  then  escapes  from  the  wounded  part 
underneath  the  dura  mater,  and  when  the  vessels  torn  are  small, 
the  compression  may  appear  slowly.  Compression  can  arise  from 
pus  which  is  formed  inside  or  outside  of  the  dura  mater.  When 
the  pus  is  external  to  the  dura  mater,  it  may  proceed  from  dis- 
eased bone  or  from  an  injury  of  the  bone;  and  finally  compres- 
sion can  arise  from  an  abscess  within  the  brain. 

Hutchinson  thinks  that  compression  rarely  arises  from 
depressed  bone,  and  though  it  may  be  requisite  to  elevate  the 
bone,  this  is  done  rather  to  prevent  inflammation  than  to  relieve 
compression. 

After  this  general  review  of  the  causes  and  effects  of  compres- 
sion of  the  brain,  the  following,  derived  in  part  from  the  author's 
own  observations,  may  be  subjoined.  Compression,  the  effect  of 
violence  acting  on  the  head,  in  most  cases  results  from  the  effu- 
sion of  blood,  which  presses  on  the  surface  of  the  brain.  Excep- 
tionally it  is  caused  by  a  portion  of  the  cranial  wall  which  has 
been  broken  and  forced  upon  or  into  the  brain.  The  patient  is 
unconscious,  one  or  both  pupils  are  dilated;  the  dilatation  is  often 
unequal.  The  breathing  is  slow,  measured,  slightly  snoring  and 
often  stertorous,  with  intervals  between  the  respirations,  similar 
to  that  occurring  in  narcotic  poisoning.  This  breathing  is  char- 
acterized by  the  peculiarity  that  the  inspiratory  act  is  the  one 
which  is  especially  prolonged,  while  that  of  expiration  remains 
almost  normal  in  its  duration.  The  interval  between  the  breaths 
is  long  in  proportion  to  the  severity  of  the  comj)ression.  The 
pulse  is  much  changed  from  normal;  it  is  slower  and  fuller,  con- 
ditions which  denote  that  the  heart  has  undergone  some  change 
in  its  mode  of  action.  The  heart,  in  the  uniformity  of  its  work, 
has  assumed  the  character  of  a  machine ;  the  pulse  wave  is  pro- 
pelled with  the  uniform  motion  of  the  piston  of  a  slowly  moving 
engine.  It  is  a  movement  stately,  measured,  and  rhythmical. 
The  hardness  or  softness  of  the  pulse  will  depend  on  the  force 
■which  the  heart  is  capable  of  exerting,  and  this  again  is  some- 
what  dependent   on   the  strength  or   weakness   of  the  subject. 


'^38  Till-:    IIKAIN. 

The  pulse  is  so  peculiar  that  it  niiglit  be  named  the  pulse  of  com- 
pression. The  temperature  may  remain  normal,  but  if  the  agent 
of  compression  develops  an  inflammation,  as  not  unfrequently  is 
the  case,  then  the  lieat  of  the  body  is  increased,  and  may  rise  to 
a  high  grade  of  temperature. 

Dingnosis. — The  foregoing  symptoms  present  themselves  in  a 
case  of  compression  uncomplicated  with  concussion  or  contusion 
of  the  brain;  yet  in  nearly  all  cases  one  or  the  other,  or  both  of 
these  conditions  are  present,  and  thus  it  is  difficult  to  determine 
the  true  nature  of  the  case,  unless  one  of  the  conditions  greatly 
predominates.  The  confusing  condition  most  commonly  present 
is  concussion,  by  which  the  pulse,  respiration,  and  motor  power 
are  greatly  weakened.  And  again  when  time  enough  has  elapsed 
for  irritation  or  inflammatory  symptoms  to  arise,  then  the  facies 
of  tlie  disease  is  changed,  and  the  symptoms  above  described  are 
essentially  altered.  From  these  facts  it  is  evident  that  the  diag- 
nostic problem  in  such  injury  sometimes  baffles  solution,  and 
thence  has  arisen  the  discrepancy  among  surgeons  who  have 
written  on  the  subject  of  cerebral  compression. 

As  aids,  however,  to  the  diagnostician  in  the  case  of  perplex- 
ity which  oftenest  presents  itself,  viz.,  to  distinguish  concussion 
and  com^jression  from  each  other,  the  following  collateral  pictures 
may  assist  in  their  comparison  and  differentiation. 

In  a  case  of  slight  concussion  there  is  some  mental  disturb- 
ance coupled  with  general  muscular  weakness.  The  action  of 
the  heart  and  lungs  is  debilitated,  and,  as  result,  the  pulse  and 
breathing  are  weak  and  slow,  and  the  temperature  is  not 
increased,  and  sometimes  it  is  slightly  lowered.  If  the  concussion 
be  more  severe,  the  patient  is  nearly  or  wholly  unconscious,  the 
heart  and  lungs  act  feebly;  no  snoring ;  the  pupils  are  equally 
dilated;  there  is  a  universal  reduction  of  the  vital  powers,  and 
reflex  action  remains,  though  in  limited  degree;  and  the  eyes 
move  torpidly  and  aimlessly  in  their  sockets;  and  the  urine 
escapes  passively.  In  a  still  higher  degree  of  concussion  the 
universal  depression  is  still  greater.  The  patient  lies  as  if  in 
deep  syncope,  with  cold  skin,  inaudible  breathing,  and  impercep- 
tible pulse;  in  fine,  in  a  moribund  state. 

Compression  does  not  occur  in  such  varying  forms  of  gradu- 
ated intensity  as  concussion  presents.  The  patient  lies  in  the 
position  of  deepest  sleep,  sleep  in  which  he  often  loudly  snores, 
and  the  lips  and  cheeks  move  as  they  do  in  the  act  of  smoking  the 
pipe.     The  tongue  lapses  towards  the  pharynx,  and  increases  the 


COMPRESSIOX    OF    THE    BRAIN.  239 

difficulty  of  breatliing.  The  patient  makes  no  voluntary  move- 
juent,  nor  can  reflex  action  be  excited;  the  pulse  is  slow,  full,  and 
for  a  time  regular;  later,  the  pulse  becomes  irregular.  The  pupils 
are  wide,  and  often  one  is  more  dilated  than  the  other,  and  the 
urine  dribbles  after  the  bladder  becomes  distended. 

As  just  stated,  compres.sion,  contusion,  and  concussion  of  the 
brain  are  often  combined  in  the  same  patient,  and  then  the  case 
may  be  represented  by  a  symbol  of  the  initial  letters  CCC,  and 
as  the  accent  or  emphasis  is  on  an}^  one  of  the  letters,  or  on  two 
of  them,  so  the  character  of  the  conditions  present  will  be  modi- 
fied and  shapen ;  and  if  two  of  the  injuries  be  equally  severe, 
then  will  the  diagnosis  be  intricate,  and  the  indications  for  treat- 
ment obscure. 

Prognosis. — The  prognosis  of  this  injury  is  one  in  which  cau- 
tion dictates  many  reservations.  For  cause  and  effect  seem  here 
sometimes  to  have  lost  their  ivonted  relations,  since  not  unfre- 
quently  a  slight  injury  may  eventuate  disastrously  and  a  grave 
one  may  proceed  rapidly  to  recovery,  thus  verifying  the  Hippo- 
cratic  axiom  that  no  cephalic  injury  is  to  be  underestimated. 

It  has  often  been  observed  that  the  symptoms  in  cerebral  com- 
pression may  gradually  subside;  for  example,  this  can  happen 
where  the  cause  is  extravasated  blood  which  is  absorbed;  also, 
when  the  compression  is  caused  by  a  depressed  bone  to  which  the 
brain  seems  gradually  to  accommodate  itself.  Such  tolerance 
may  be  brought  about  by  the  retirement  of  some  of  the  fluid  con- 
tents of  the  brain,  viz.,  of  blood  and  the  cerebro-spinal  fluid. 
Besides,  it  has  been  observed  that  where  pressure  is  maintained 
for  a  long  time  on  a  portion  of  brain,  this,  similar  to  any  part 
that  is  long  jDressed  upon,  atrophies  or  lessens  in  volume.  Hence 
the  tolerance  of  pressure  is  acquired  through  permanent  struc- 
tural impairment,  a  fact  which  should  be  considered  in  progno- 
sis. In  cases  in  which  compression  is  caused  by  a  neoplasm,  or 
through  an  accumulation  of  pus,  then  the  prognosis  is  entirely 
inauspicious.  Improvement  can  only  be  gained  through  some 
perilous  surgical  procedure. 

The  prognosis  is  most  favorable  in  cases  in  which  compression 
has  instantly  arisen  from  a  depression  of  bone.  It  is  less  favor- 
able in  cases  in  which  compression  has  come  on  some  minutes 
or  a  short  time  after  the  injury,  for  in  such  patients  a  rupture  of 
a  blood-vessel  may  be  suspected,  and  a  subsequent  effusion  of 
blood.  There  is  a  third  class  of  cases,  in  winch  the  symptoms  of 
compression  only  supervene  some  days  after  the  injury,  and  in 


240  THE    BRAIN, 

which  it  is  due  to  the  swelling  of  the  brain  through  inflamma- 
tory action.  In  such  cases,  besides  the  afflux  of  blood,  there 
occurs  also  an  emigration  of  cells  from  the  vessels  into  the 
adjacent  tissues;  and  perhaps  there  is  also  a  cell  j^roliferation. 
Through  these  several  agencies,  the  volume  of  the  brain  is 
enlarged  and  crowded  against  the  unyielding  cranial  wall,  and 
thus  compression  arises,  of  which  the  prognosis  is  very  unfa- 
vorable. 

Treatment. — In  the  treatment  of  compression,  the  question 
of  operative  interference  is  one  which  has  been  agitated  and 
discussed  by  surgeons,  and  at  different  periods  interference  or 
non-interference  has  predominated.  This  matter  is  a  part  of  the 
history  of  the  trephine,  and  has  been  considered  in  a  preceding 
section,  in  wdiich  this  operation  was  treated  of.  The  treatment 
is  most  properly  considered  under  different  headings. 

First,  in  the  case  in  which  compression  is  produced  by  a 
smaller  or  larger  portion  of  the  cranial  wall  that  has  been  forced 
inwards  and  crowded  on  the  adjacent  brain:  though  the  brain 
may  tolerate  this  violence,  and  finally,  as  it  were,  forget  the  intru- 
sion, yet  this  is  a  case  in  which  the  trephine  should  be  employed. 
The  effect  of  trephining  will  be  to  place  the  encephalic  structures 
in  such  condition  that  the  blood  will  circulate  normally,  and 
thus  a  proper  balance  is  restored  between  the  defect  at  one  point 
and  the  excess  at  another  one;  ansemia  and  hyperasmia  both 
give  place  to  equal  diffusion  of  blood.  And  if  the  brain  moves, 
as  some  contend,  with  the  influx  and  efflux  of  the  blood,  then  an 
operation  is  indicated  to  remove  the  encroaching  portion  of  the 
wall,  which  must  interfere  with  the  normal  influent  movement. 
The  onerative  work  to  be  done  will  consist  of  trephining  a  small 
orifice,  through  which  the  elevator  can  be  passed,  and  the  wall 
uplifted  and  restored  to  its  original  position  and  level.  When 
the  depression  has  been  great,  after  it  has  been  elevated  theri- 
sometimes  remains  a  hollow  space  for  a  time;  especially  is  this 
so  where  the  depression  has  existed  so  long  that  the  inherent 
elasticity  of  the  structures  has  been  partly  extinguished.  As,  in 
such  a  case,  there  would  be  a  tendency  of  the  blood  to  exude  and 
fill  the  vacant  space,  there  should  be  provided  drainage  for  the 
effused  fluid,  for  a  day  or  two;  a  drainage  tube  should  be  allowed 
to  remain  as  long  as  there  is  any  escape  of  fluid.  The  stage  of 
inflammation,  which  is  impending  in  every  such  injury,  should 
be  forestalled,  curtailed,  and,  if  possible,  prevented  by  rigid  anti- 
phlogistic treatment.     The  ice-bag  should  be  at  once  placed  about 


COMPRESSION    OF    THE    BRAIX.  241 

the  head.  The  head  should  be  somewhat  uplifted,  warmth 
applied  to  the  feet,  and  the  patient  have  perfect  rest  of  mind  and 
sense.  If  the  subject  be  plethoric  and  have  an  ample  endowment 
of  physical  strength,  then  he  must  be  bled  from  the  arm;  not  less 
than  twenty  ounces  of  blood  should  be  withdrawn.  xVs  internal 
medicine,  cathartics  should  be  given  in  the  commencement;  also 
iodide  of  potassium, combined  withthebromide  of  potassium,  should 
immediately  be  commenced  with,  and  continued  for  some  weeks. 
The  submuriateof  mercury,  once  in  so  much  favor  as  a  controller 
of  cerebral  inflammation,  should  not  be  forgotten ;  the  disrepute 
into  wdiich  it  has  fallen  in  recent  years  is  unmerited;  the  spectre 
of  ptyalism  which  hovers  in  the  popular  mind  as  an  objection  to 
the  use  of  mercurials,  will  be  conjured  away,  if  the  remedy  be 
administered  wuth  properly  w^atchful  precautions.  Tlie  calomel 
ma}^  be  given  in  doses  of  a  half  grain  every  four  hours;  and 
should  signs  of  its  specific  effect  appeaT  in  an  increased  flow  of 
saliva,  and  swelling  of  the  alveolar  integument,  then  the  remedv 
should  be  suspended  for  a  few  days.  Another  remedy,  whicli 
rarely  disappoints  in  its  action,  is  the  protiodide  of  mercury,  w'hicli 
may  be  given  in  doses  of  a  half  grain  three  times  a  day. 

The  anticipated  benefits  of  treatment  in  cases  of  cerebral 
compression  from  depressed  bone  are  often  not  realized,  since  the 
injury  is  frequently  associated  with  concussion  or  contusion, 
especially  with  the  latter.  The  in-pressed  bone  can  hardly  fail  to 
bruise  the  underlying  brain,  and  hence  the  antiphlogistic  reme- 
dies mentioned  should  have  early  and  vigorous  use;  and  they 
must  be  continued  for  not  less  than  four  weeks,  and  the  adniinis- 
tration  should  be  continued  much  longer  in  cases  in  which  motor, 
sensory,  or  mental  disturbance  points  to  organic  lesion. 

The  next  form  of  compression,  of  which  the  treatment  is  now 
to  be  considered,  is  that  arising  from  effusion  of  blood  from  one  or 
many  ruptured  vessels.  The  indication  of  such  ruptures  will  be 
that  the  compression  supervenes  gradually;  for  its  complete  appear- 
ance, minutes  or  even  an  hour  or  more  of  time  maybe  required;  if 
it  appears  cjuickly,  a  vessel  of  considerable  calibre  must  have  been 
opened.  As  treatment  where  such  vascular  rupture  is  suspected, 
the  bold  prophylactic  measure  of  ligating  the  vessel, which  supplies 
the  blood  for  ecchymosis,  has  been  recommended;  thus,  it  has 
been  proposed  to  tie  the  external  carotid  ta  check  bleeding  from 
the  meningeal  arteries,  and,  as  a  more  radical  procedure,  in  1863, 
Furneaux  Jordan  recommended  the  ligation  of  the  common 
carotid  artery;  for,  if  this  be  done,  effusion  of  blood  from  rupture 


'242  THK    I'.KAIN. 

of  the  middle  lueningeal  artery  or  of  a  branch  of  tlie  iiilernal 
carotid,  would  be  coutroUed.  This  ligation  would  control  the 
tendency  to  intlamination  of  the  injured  brain.  According  to 
Jordan,  the  results  of  ecchymosis  of  blood  from  the  ruptured 
meningeal  artery  are  hemiplegia,  snoring,  whifHng  of  air  from 
the  side  of  the  mouth  on  the  affected  side;  the  pu})il  is  insensible 
to  liirht.  and  control  of  the  rectum  and  bladder  is  lost;  as  soon  as 
these  symptoms  appear,  one  should,  according  to  Jordan,  tie  the 
carotid  on  the  side  opi)Osite  to  the  hemiplegia.  And  the  author 
will  add  to  this  advice  to  bleed  the  patient  freel}'.  Without  this 
precaution,  the  tension  with  which  the  blood  is  carried  to  the 
brain  through  the  remaining  carotid  is  abnormally  great,  and 
must  cause  disturbance  of  nutrition;  the  abstraction  of  blood 
would  lessen  such  disturbance. 

A  question  next  to  be  determined  is  whether  there  are  indica- 
tions present  which  demand  or  justify  the  use  of  the  trephine. 
The  mass  of  surgical  authority  favors  the  use  of  the  trephine;  for 
none  deny  that  the  presence  of  a  large  clot  of  blood  must  be 
detrimental  to  the  brain,  and  most  agree  that  its  removal  is 
necessary.  The  opponent  of  trephination  claims,  however,  that 
the  work  will  be  done  by  absorption.  It  may  be  conceded  tliat 
this  is  partially  possible,  yet  not  wholly  so;  some  remnant  of  the 
coagulum  will  remain  as  inert  material,  and,  by  its  presence,  will 
act  the  part  of  a  foreign  body  which  has  become  encysted. 
During  the  period  of  absorption  the  brain  adjacent  to  the  clot 
will  be  rendered  ansemic,  and  must  iindergo  some  atrophic 
change;  hence,  it  is  manifest  that  the  expectant  method  of  non- 
interference has  its  disadvantages. 

General  Consideration  of  the  Conditions  wJiicJi  favor  or  contra- 
indicate  Trephining. — A  few  years  ago,  Leon  Le  Fort,  and,  still 
more  recently,  Laugier  have  made  an  exhaustive  study  of  the 
hterature  of  cerebral  injury,  and  each  has  endeavored  to  point 
out  the  indications  for  the  use  of  the  trephine. 

Le  Fort  groups  together  the  symptoms  which  can  arise  from 
lesion  of  the  brain  in  three  general  classes,  as  follows:  (1)  Coma, 
insensibility,  and  stupor,  that  is  often  associated  with  stertor, 
which  commence  with  and  continue  after  the  accident.  (2)  Fever, 
agitation,  delirium,  pains  in  the  head,  and  epileptiform  convul- 
sions. (3)  Hemiplegia  with  or  without  slight  convulsions.  When 
the  first  group  of  symptoms  is  present,  and  if  the  coma  be  deep, 
and  there  is  a  total  loss  of  muscular  power,  then  it  is  better  not 
to  operate;  or  if  this  be  done,  one  should  wait  until  the  cerebral 


COMPRESSIOX    OF    TPIE    BRAIX.  243 

depression  has  abated  or  subsided.  Trephining  in  such  cases  has 
been  followed  by  a  mortality  of  twenty-five  per  cent.  The  second 
class  of  symptoms  is  indicative  of  a  limited  lesion  of  the  brain, 
and  of  a  limited  or  general  inflammation  of  the  organ;  there  is 
no  satisfactory  indication  for  trephining  in  such  cases,  and  when 
the  operation  has  been  done,  it  has  seemed  to  provoke  or  increase 
the  inflammation.  Should  the  convulsions  occur  immediately 
after  the  injury,  then,  as  probable  signs  of  some  compression,  they 
would  justify  the  use  of  the  trephine;  yet  if  the  convulsions  occur 
at  a  later  period,  they  indicate  an  inflammation  which  has  arisen 
around  a  contusion  of  the  organ;  and  trephining  has  resulted 
disastrously  in  such  condition,  viz.,  the  mortality  was  ninety-four 
per  cent.  Finally  hemiplegia,  isolated  or  associated  with  spasms 
which  are  limited  to  the  palsied  limbs,  is  deemed  a  sign  of  com- 
pression, and  an  indication  for  trephining.  This  compression 
can  arise  from  a  depressed  bone,  yet  it  arises  more  commonlv 
from  an  ecchymosis  of  blood. 

To  sum  the  subject  up  briefly,  Le  Fort  says  that  there  are 
three  orders  of  morbid  phenojnena  which  result  from  blows  and 
other  injuries  of  the  head  and  which  govern  the  use  of  the  tre- 
phine, viz.,  coma,  convulsions,  and  hemiplegia.  In  coma,  the  rule 
is  to  wait;  in  convulsions,  one  should  never,  or  almost  never, 
trephine;  but  in  hemiplegia,  without  or  with  limited  spasms,  the 
indication  is  to  trephine,  and  to  do  this  at  an  early  period.  And 
if  the  morbid  conditions  only  occur  secondarih^,  and  there  is  the 
presumption  that,  with  the  effusion  of  blood,  there  is  a  fracture, 
then  one  should  operate.  And,  finally,  as  an  apothegmatic  rule 
of  guidance  in  conditions  of  uncertainty,  Le  Fort  lays  down  the 
follow'ing:  In  all  cases  where  doubt  exists  one  should  act. 

Tangier  discusses  the  points  for  and  against  trephining  in 
those  cases  in  which  there  is  evidence  or  presumption  of  an 
ecchymosis  of  blood.  He  finds  that  almost  all  agree  that  the 
unilateral  palsy  is  on  the  side  opposite  to  ecchymosis;  yet,  before 
the  trephine  is  used,  there  must  be  found  some  local  injury  which 
can  serve  as  a  guide  for  the  point  of  opening  the  skull ;  in  such 
cases,  nearly  all  authority  is  unfavorable  to  operating.  Van 
Swieten  alone  advises  to  open  guidelessly  the  parietal  region, 
since  the  leading  vessels  run  beneath  the  parietal  bone.  Again, 
the  local  injury  and  the  hemiplegia  are  exceptionally  on  the 
same  side  of  the  body,  and,  though  a  probable  explanation  of  this 
is  that  there  has  been  a  rupture  by  contre-coup,  yet  there  is  too 
much  uncertainty  as  to  the  site  to  justifv  one  in  trephining  ;  in 


244  THE    BRAIN. 

such  cases  the  operation  is  not  justiiiable.  But  when  the  local 
injury  coiTes})onds  to  a  sinus  of  the  <lura  mater,  or  to  the  middle 
meningeal  artery,  and  the  palsy  is  on  the  opposite  side,  then  one 
may  trephine  at  the  site  of  injury.  Again,  when  the  causal 
injury  is  an  open  wound,  yet  too  small  to  permit  the  effusing 
blood  to  escape,  then  some  counsel  to  introduce  a  wedge  of  dry 
wood  between  the  fragments,  and  thus  to  forcibly  enlarge  the  o{)en- 
ing;  a  much  better  ])lan  would  be  to  use  the  trephine  and  make 
an  opening  at  once. 

Fr()m  the  facts  and  opinions  which  have  been  presented  there 
may  be  derived,  as  })ractical  rule  Ibr  guidance,  to  use  the  tre})hine 
in  all  cases  in  which  there  is  unilateral  l)alsy  resulting  from 
blood  ecchymosed  into,  or  upon  the  brain.  The  removal  of  the 
clot  is  especially  indicated  when  aphasia  is  conjoined  to  the 
hemiplegia.  The  removal  of  the  clot  is  not  always  an  easy  matter, 
even  though  it  be  reached;  sometimes  it  is  spread  out  over  so 
large  a  surface  that  much  of  the  clot  is  inaccessible.  And,  again, 
(hough  it  be  removable  through  localized  isolation,  yet  the  clot 
may  soon  reform  through  the  continuance  of  the  bleeding,  and 
thus  the  surgeon  will  be  frustrated  in  the  object  of  his  work.  In 
the  former  case,  in  which  there  is  a  widespread  coagulum,  besides 
the  scoop,  the  syringe  might  boused,  and  a  weak  sublimated  solu- 
tion should  be  used  for  washing  out  the  blood.  Due  precaution 
should  be  used  in  this  injection  not  to  detach  the  dura  mater 
around  the  injury.  And  in  tlie  case  in  which  the  clot  reforms, 
the  external  carotid  artery,  or  the  common  trunk,  may  be  tied; 
and  thus  both  bleeding  and  inflammation  will  be  controlled.  In 
these  operations  the  wound  should  be  subsequently  carefully 
drained;  and  if  there  be  disintegrating  clotted  blood  escaping, 
the  exit  of  this  should  be  favored  b\^  ablution,  which  will  be 
most  safely  done  by  the  use  of  fluid  })asscd  through  a  siphon,  or 
irrigator  held  at  short  distance. 

Compression,  as  before  stated,  can  arise  from  a  neoplasm,  or 
from  an  accumulation  of  ])us  within  the  cranium.  The  recent 
advances  in  tlie  knowledge  of  cerebral  localization  before  referred 
to,  have  added  much  to  the  accuracy  in  the  location  of  pus,  or  a 
neoplasm  in  the  brain;  the  peripheral  disturbance  in  limb, 
muscle,  or  sense,  serves  to  determine  with  much  definiteness  the 
site  of  the  encephalic  disturbance,  enough  so,  at  least,  to  prevent 
the  use  of  a  half  score  or  more  of  tre[>liine  crowns,  as  was  the 
wont  of  old,  to  discover  the  disturbing  agent  within  the  cranium. 
It  must  be  confessed,  however,  that  much  is  yet  to  be  learned; 


CONTUSION    OF    THE    BRAIN.  245 

niid  that,  as  in  our  earth  large  polar  and  equatorial  regions  are 
3''et  terra  incognita,  so  in  the  cranial  sphere  there  is  much  that  is 
unknown,  and,  from  its  nature,  it  is  destined  to  remain  so. 

When  the  location  of  a  tumor  can  be  determined,  which  from 
its  volume  is  causing  compression,  the  indication  is  clear  that  if 
the  anatomical  conditions  are  such  as  will  permit  the  removal  of 
the  growth,  the  attempt  should  be  made  to  do  so;  should  the 
neoplasm,  however,  be  intrenched  in  some  anatomically  inap- 
proachable site,  then  the  patient  must  be  committed  to  his  fate. 

And  similar  principles  should  serve  for  the  guidance  of  the 
surgeon  in  reference  to  the  use  of  the  trephine  for  the  liberation 
and  escape  of  pus  from  the  cranial  cavity.  The  operator  here 
has  generally  the  advantage  of  a  local  sign  which  will  serve  as  a 
guide  for  his  perforation;  the  pericranium  overlying  the  puru- 
lent collection  wdll  be  found  loosely  adherent  to,  or  perhaj)s 
detached  from,  the  skull.  The  skull  itself  will  present  some  devi- 
ation from  the  normal  appearance.  A  similar  alteration  in  the 
appearance  of  the  bone  has  been  observed  in  cases  in  which  there 
was  subjacent  ecchymosis  of  blood.  This  has  been  noted  by 
several  English  surgeons.  After  the  wall  has  been  opened,  some- 
times the  pus  is  not  at  once  found;  it  may  be  beneath  the  mem- 
branes, or  within  the  brain  itself.  Such  subjacent  pus  is  denoted 
by  alteration  in  the  hue  and  texture  of  the  covering  membrane. 
And,  further,  when  the  pus  lies  in  the  brain,  the  overlying 
stratum  of  cerebral  matter  is  motionless;  the  pulsating  move- 
ment that  is  present  in  the  normal  healthy  brain  is  absent. 
With  such  signs  for  guidance,  Dupuytren  plunged  his  bistoury 
into  the  overlying  brain,  and  discovered  pus;  the  story  of  this 
case  is  universally  quoted  in  surgical  literature,  and  has  since 
had  a  following  In  practice. 

If  pus  be  found,  provision  must  be  made  for  its  ready  dis- 
charge; viz.,  after  opening  and  carefully  w^ashing  out  the  pus 
cavity,  a  drainage  tube  should  be  inserted,  and  through  this  daily 
ablution  should  be  made  with  a  sublimated  solution. 

Contusion  of  the  Brain. — It  is  only  within  comparatively  recent 
years  that  contusion  of  the  brain  has  been  carefully  studied,  and 
this  study  has  been  embarrassed  by  the  circumstance  that,  nearly 
always,  there  are  associated  with  the  effects  of  contusion  also 
those  arising  from  concussion  or  compression ;  in  fact,  it  is  diffi- 
cult for  contusion  to  occur  without  there  being  also  some  concus- 
sion. 

As  causes  of  contusion  may  be  cited  various  kinds  of  violence 


246  '  THE   BR.vrx. 

acting  directly  or  indirectly  on  the  cranium.  The  violence  may 
drive  the  wall  inwards  for  an  instant,  and  tiicn  it  may  return  as 
(juickly  to  normal  form  again;  that  is,  through  tiie  ordinary 
action  of  elasticity,  of  which,  as  early  stated  in  this  work,  the 
skull  has  ample  endowment.  Through  such  momentary  impres- 
sion the  adjacent  encephalic  structures,  viz.,  tlie  membranes  and 
the  underlying  brain,  are  bruised  to  a  limited  extent.  Such 
lesion,  according  to  the  degree  of  violence,  may  act  only  on  the 
cellular  cortex,  or,  besides  this,  the  injury  may  reach  into  the 
subjacent  fibri Hated  matter. 

Again,  contusion  may  result  from  violence  in  which  the 
cranial  wall  is  fractured,  and  the  fragments,  or  fractured  edges  of 
bone,  are  driven  against  and  bruise  the  underlying  soft  structures. 
In  this  form  of  contusion  there  may  he  an  open  wound  through 
which  the  substance  of  the  injured  ])rain  may  exude,  and  the 
conditions  are  such  that  the  wounded  parts  may  be  somewhat 
open  to  inspection  with  the  eye. 

There  may  be  contusion  affecting  the  cerebellum  as  well  as 
the  cerebrum;  yet  the  latter,  from  its  larger  volume  and  greater 
surface,  is  more  frequently  injured.  There  may  be  single  or 
multiple  points  of  contusion.  And  when  the  violence  has  acted 
by  contre-coup,  it  is  probable  that  the  primary  point  of  impact 
is  likewise  contused  as  much  or  more  than  the  one  opposite  to  it. 

The  conditions  found  where  the  brain  has  been  contused  are 
the  following:  A  few  drops  of  effused  blood  lie  in  softened 
cerebral  substance,  wdiich  is  easily  distinguished  from  the  sur- 
rounding unaffected  cerebral  substance.  Tlie  softening  is  njostly 
superficial,  or  it  may  reach  into  tlie  white  matter  of  the  brain. 
There  may  l)e  several  points  of  softened  structure.  The  softening 
is  such  that  the  atfected  material  can  l)e  washed  away  with  a  fine 
stream  of  flowing  water.  Wlien  the  softened  matter  is  washed 
away,  there  remain  slight  hollows  or  depressions  of  violet  or 
slate-colored  tint.  Sometimes  the  arachnoid  and  i)ia  mater  are 
found  torn.  After  some  days  in  the  course  of  the  disease,  pus 
forms  and  spreads  out  over  the  adjacent  surface  of  the  brain. 

In  all  fractures  of  the  skull,  whether  concealed  or  open  through 
a  wound  of  the  scalp,  contusion  of  the  brain  is  to  be  feared; 
the  agent  whicii  caused  the  fracture,  may  penetrate  deeply  enough 
to  bruise  the  brain;  and  when  the  brain  remains  depressed,  it 
hastens  tlie  disorganization  of  the  contused  structure. 

To  Dupuytren  is  due  the  credit  of  having  first  observed  and 
described  contusion  of  the  brain;    and  according   to    him   the 


COXTUSIOX    OF    THE    BEAIX.  247 

symptoms  arising  from  the  injury  do  not  appear  until  the 
fourth,  fifth  or  sixth  day  after  the  action  of  tlie  causal  violence; 
and  the  symptoms  thus  appearing  are  those  of  inflammation  of 
the  brain  and  its  membranes;  for  example,  there  occur  chills, 
fever,  delirium,  muscular  contraction  and  spasms  on  one  side  of 
the  body,  provided  the  lesion  is  unilateral;  later  there  are  com- 
pression and  complete  pals}^  of  one  side,  and  in  most  of  the  cases, 
the  patient  dies.  Dupuytren  states  that  persons  so  wounded  often 
walked  to  the  hospital,  and  after  their  reception  there,  for  a  few 
days  they  exhibited  no  grave  symptoms;  then  suddenly  the  con- 
ditions mentioned  were  ushered  in.  Sanson  claims  that  there  are 
evidences  of  contusion  from  the  commencement  of  the  injury. 
Such  symptoms  are  the  contraction  of  one  lid,  and  the  narrowing 
of  a  pupil,  spasmodic  movement  of  the  lips  and  of  one  or  more 
muscles  of  the  face;  besides  there  is  a  difficulty  of  pronouncing 
some  words,  with  headache,  and  a  general  agitation  of  the  body. 
These  symptoms  are  at  first  without  fever;  but  after  four  or  five 
days,  fever  arises.  Laugier,  however,  has  seen  contusion  in 
which,  as  is  asserted  by  Dupuytren,  there  were  no  antecedent 
symptons  during  the  first  few  days. 

Boinet,  in  184S,  on  the  subject  of  cerebral  contusion,  announced 
that  the  following  conditions  are  present:  There  is  strong  con- 
traction of  the  limbs,  general  agitation  of  the  body,  unconscious- 
ness and  stertorous  breathing.  In  mild  cases  there  is  contraction 
of  one  e_yelid,  narrowing  of  one  pupil  and  inability  to  pronounce 
certain  words.  There  is  also  pain  in  the  side  of  the  head  which 
is  injured.  These  signs  of  contusion  appear  at  once,  or  within  a 
short  time  after  the  receipt  of  the  injury.  The  symptoms  of 
contusion  are  often  concealed  by  those  of  concussion  and  com- 
pression. 

Prognosis. — The  chances  of  recover}^  in  a  case  of  severe  contu- 
sion of  the  brain  depend  on  whether  there  is  associated  with  it  an 
open  wound  or  not;  an  opening  to  the  contused  structure  is  a 
condition  greatly  favorable  to  recovery,  since  the  structural  ele- 
ments which  are  destroyed  can  escape.  Cases  have  been  treated 
by  the  writer  in  which  the  skull  was  fractured,  a  fragment  of  bone 
detached  so  that  there  was  a  free  opening  to  the  cerebral  structure, 
which  was  severely  contused  and  lacerated,  and  yet,  despite  the 
severe  wound  and  considerable  loss  of  cerebral  matter,  through 
the  open  state  of  the  wound,  the  patient  made  his  escape  from  a 
contusion  of  the  brain  that  surely  would  liave  destroyed  his  life 
had  the  wound  been  a  closed  one.     If  the  contusion  be  a  severe 


248  THE    BRAIN. 

one  involving  the  death  of  a  small  tract  of  the  surface  of  the  brain, 
tlien  suppuration  must  result.  Such  pus  must  continue  to  increase 
in  amount,  and,  necessarily,  have  a  disastrous  termination;  only 
in  mild  cases  of  contusion,  iu  which  the  mere  surface  of  the  brain 
is  injured,  is  it  conceivable  that  the  injured  elements  can  be 
absorbed,  and  the  patient  recover;  but  such  absorption  and 
resolution  are  impossible  where  there  is  extensive  contusion  with 
unopened  cranial  wall.  Though  cures  in  such  cases  have  fre- 
quently been  proclaimed,  yet,  as  Laugier  remarks,  where  is  the 
evidence  that  the  brain  was  severely  contused?  The  unopened 
skull  conceals  the  true  conditions;  the  peripheral  manifestations 
probably  gave  an  exaggerated  report  of  the  intra-cranial  injury; 
and  what  was  deemed  a  severe  contusion,  was  probably  only  a 
slight  vertical  bruise.  In  fact,  the  surgeon  has  been  misled  by 
the  absence  of  peripheral  manifestations  which  are  usually  pres- 
ent; a  few  cases  have  been  seen  which  ended  fatally,  in  which 
the  necro[)sy  revealed  some  cerebral  contusion  in  which  the 
peripheral  manifestations  had  been  wholly  wanting.  It  may  be 
predicted  that  cases  will  end  in  death,  in  which  there  has  been 
severe  contusion  of  the  brain,  in  which  the  injury  has  penetrated 
deeply,  and  the  skull  was  not  opened;  and  the  escape  from  death 
can  only  occur  through  an  opening  made  either  by  the  causal 
injury  or  the  surgeon's  trephine.  But  in  superficial  contusion, 
recovery  may,  with  a  fair  degree  of  certainty,  be  predicted. 

Treatment. — Since  the  efiects  of  contusion  do  not  reveal  tlj em- 
selves  immediately,  there  is  an  interval  in  which  preventive  or 
proph3dactic  measures  may  be  used;  among  such  njeasures,  one 
of  the  best  in  the  plethoric  suljject  is  bleeding,  done  with  the 
lance  from  the  arm,  or  with  leeches  from  the  temples  or  regions 
lying  over  the  emissaries  of  Santorini  or  trans-cranial  foramina. 
Boinet,  to  whom  reference  has  been  made,  recommends  that  the 
patient  should  be  leeched  behind  the  ears.  The  head  should  be 
covered  with  an  ice-bag,  and  the  patient  should  be  restricted  to 
low  diet,  and  the  bowels  well  emptied.  In  this  way  the  develop- 
ment of  inflammatory  symptoms  may  be  prevented.  Still,  if  the 
contusion  be  severe,  and  has  penetrated  deeply,  these  primitive 
measures  will  fail  to  accomplish  this  purpose;  chills,  fever, 
increase  of  heat,  and  the  general  sym})tom3  of  encephalitis,  will 
appear  about  the  fifth  or  sixth  day,  and  portend  great  peril  to 
the  patient's  life.  Should  these  symptoms  increase  in  gravity, 
then,  at  an  early  period,  taking  a  lesson  from  the  favorable  course 
which  is  often  seen  where  the  wound  is  an  open  one,  the  surgeon 


CONTUSION    OF    THE    BRAIN.  249 

would  be  justified  in  using  the  trephine  and  making  an  opening 
to  the  contused  structure,  which  is  probably  in  process  of  suppu- 
ration. For  this  object,  a  small  opening  will  suffice,  and  when 
made,  the  membranes  if  closed  should  be  incised,  and  a  free  exit 
provided  for  pus  and  other  disintegrating  material;  thus  doing, 
the  surgeon  would  open  a  door  for  the  escape  of  a  patient  who, 
otherwise,  was  certainly  destined  to  die. 


1  / 


CHAPTEIl    VI. 


ENCEPHALITIS,  OR    INFLAMMATION    OF    THE    BRAIN. 

Pure  inflaujination  of  the  brain  is  a  morbid  process  which  is 
first  concerned  with  the  interstitial  structure;  next,  the  vessels 
become  accessorily,  or  secondarily,  aflected.  In  paralysis  in  which 
there  is  found  change  in  the  cells  and  their  nuclei,  the  condition 
is  not  an  inflammatory  one,  and  hence  it  is  claimed  that  a 
parenchymatous  inflammation,  in  which  all  the  elements  of  the 
brain  are  involved,  docs  not  exist.  Though,  in  nosological 
nomenclature,  the  terms  encephalitis,  cerebritis,  and  cerebral  and 
cerebellar  inflammation,  are  in  use,  yet  it  must  be  admitted  that  a 
purelv  isolated  inflammation  of  the  cerebrum  or  cerebellum  can- 
not exist;  the  investing  membranes  must,  also,  be  involved  in  an 
inflammation ;  hence  the  name  meningo-encephalitis  is  often  used 
to  designate  the  disease;  and  when  the  development  and  cause 
of  tlie  disease  are  studied,  since  the  membranes,  especially  the  })ia 
mater,  are  the  first  to  be  affected,  the  most  rational  name  for  the 
disease  must  be  one  in  which  there  is  reference  to  all  the 
structures  implicated  in  the  inflammation. 

Causes. — The  chief  causes  are  traumatic,  in  which  the  brain  is 
directly  injured.  Examples  of  these  are  falls  upon  the  head,  or 
blows  on  the  head;  and  in  each  case  the  cranium  may  or  may  not 
be  broken.  When  there  is  no  fracture,  the  inflammation  can  arise 
from  both  contusion  and  concussion;  it  can  be  caused  by  com- 
pression in  which  the  in-driven  wall  injures  the  part  against 
which  it  presses.  Or  the  wall  may  be  broken  into  fragments,  of 
which  cneormore  pieces  wound  and  inflame  the  brain.  In  open 
wounds  of  the  scalp  coexisting  with  comminition  of  the  bone, 
fragments  of  the  latter  can  be  forced  into  the  brain,  and  soon 
awaken*  an  inflammation,  which,  local  at  first,  soon  involves 
adjacent  parts. 

A  frequent  cause  is  caries  of  bone  forming  a  part  of,  or 
adjacent  to,  the  cranial  cavity;  the  bones  most  liable  to  such  dis- 
ease are  those  forming  the  upper  and  deeper  portions  of  the 
(  250  ) 


CAUSES    OF    INFLAMMATION    OF    THE    BEAIN.  251 

nasal  fossae,  and  also  the  mastoid  and  ^petrous  portions  of  the 
temporal  bone.  According  to  Toynbee,  the  location  of  the  dis- 
ease in  the  auditory  region  determines  the  point  of  attack  upon 
the  brain;  namely,  when  the  external  auditory  canal  is  affected 
the  disease  is  more  apt  to  pass  to  the  cerebellum.  Affection  of 
the  tympanum  oftener  awakens  cerebritis,  while  if  the  caries 
be  located  in  the  labyrinth  the  inflammation  oftenest  passes  to 
the  medulla  oblongata.  Other  observers  have  met  with  frequent 
exceptions  to  the  rules  of  Toynbee  here  stated. 

According  to  the  researches  of  Hayem,  the  inflammatory 
process  pursues  the  same  course  in  the  structures  of  the  brain  as 
it  does  elsewhere.  There  is  a  proliferation  of  the  constituent 
cells,  and  a  structural  development  of  which  the  component 
element  is  the  embryonic  or  granulative  cell.  The  terminations 
are  similar  to  those  of  inflammation  elsewhere,  viz.,  suppura- 
tion or  granulative  tissue,  which  may  end  iu  a  cicatrix.  Or  the 
process  may  recede  through  the  vanishing  of  the  hypergemia 
and  dispersion  of  the  new  bone-cells. 

Encephalitis,  when  it  assumes  the  hyperplastic  form,  may  be 
diffused  or  circumscribed  in  character.  The  diffused  form  may 
involve  a  large  part  of  the  brain.  This  form  is  often  seen  in 
infants,  and  then  does  not  fall  within  the  domain  of  the  surgeon. 
In  the  circumscribed  form  the  hyperplastic  product  is  limited 
to  a  small  space.     This  form  of  the  disease  has  rarely  been  seen. 

The  suppurative  event  of  encephalitis  may  appear  in  three' 
different  forms,  namely,  purulent  infiltration,  abscess  with  infiltra- 
tion of  the  adjacent  structure,  and,  thirdly,  circumscribed  abscess. 

It  is  seldom  that  one  has  an  opportunity  of  observing  in 
man's  brain  the  condition  of  the  parts  which  precedes  the  forma- 
tion of  pus;  the  most  that  is  known  has  been''  learned  from 
experiments  that  have  been  made  on  aninjals.  If  the  brain  of 
an  animal  be  locally  irritated,  there  will  be  observed  a  multipli- 
cation of  cells,  which  spring  from  the  stroma,  named  here  neu- 
roglia, of  the  brain.  This  cell  growth  is  preceded  first  by  a  tume- 
faction of  the  cells  of  the  wounded  stroma.  A  similar  action 
occurs  in  tlie  constituent  cells  of  the  walls  of  the  vessels.  As 
the  process  advances,  the  new  cells  are  infiltrated  into  the  inter- 
cellular substance.  Nucleated  cells  appear  free  or  detached,  and 
these  are  pus-cells.  As  occurs  on  the  surface  of  the  body  in  an 
inflamed  structure,  so  here  we  have  an  exuberant  development 
of  cells,  the  most  of  which,  not  being  organized,  aid  in  the  gen- 
eration of  pus;  and  these  cells  arise  in  part  from  the  neuroglia, 
and  in  part  through  emigration  from  the  vessels. 


252  KNCKI'IIA  LITIS,    OK    INFLAMMATION    OF    THE    BRAIN. 

When  tlio  event  is  abscess,  this  is  situated  most  frequently  in 
the  white  matter  of  the  brain,  and  it  is  found  oftenest  in  the 
cereljrum.  tstill  abscess  has  been  found  in  the  cerebellum,  also 
in  the  pituitary  body,  and  in  the  medulla  oblongata.  The 
abscess  may  be  multiple  or  single.  When  multiple  the  volume 
is  smaller  than  where  but  one  exists.  At  first  the  containing 
wall  is  irregular  and  softened  ;  later,  a  cyst-like  wall  is  formed. 
The  abscess  may  remain  (luiescent  without  change  for  a  long 
time,  or  it  may  burst  into  an  adjacent  ventricle,  or  open  on  the 
surface  of  the  brain;  and  in  this  change  of  site  it  can  awaken 
an  inflammation  in  the  parts  with  which  it  comes  in  contact. 
An  unusual  event  of  such  abscess  is  that  it  may  ulcerate  through 
the  cranial  wall  and  appear  under  the  scalp.  Such  pus  has 
opened  into  the  aural  cavity.  In  case  the  abscess  becomes 
encysted,  some  months  are  needed  for  the  formation  of  a  firm 
containing  wall.  The  pus  cavity  may  contract  through  change 
in  its  contents.  The  })us  does  not  putrefy  or  acquire  an  ill  odor 
unless  it  comes  in  contact  with  the  air. 

Symptoms. — Inflammation  here,  as  elsewhere,  changes  with- 
out abolishing  the  functions  of  the  afiected  structures.  And  as 
the  result  of  an  increased  supply  of  blood,  tlie  earliest  change  is 
functional  exaltation;  and  as  the  inflammation  exists  in  vary- 
ing grades  of  intensity,  so  there  are  variations  of  excitation,  from 
that  wdiich  is  scarcely  apparent  to  that  which  is  an  entire  })er- 
version  of  the  functions  of  the  part.  To  formulate  a  description 
which  will  comprise  the  different  phases  of  functional  perversion 
is  difficult,  if  not  impo.ssible;  and  this  could  hardly  be  other- 
wise when  we  consider  the  diversity  o£  causation.  For  example, 
the  presence  of  the  inflammatory  tract,  or  the  continuance  of  the 
primarily  exciting  cause,  will  determine  oedema  or  congestion 
in  the  parts  contiguous;  a  serous  eff'usion  into  the  ventricles  may 
thus  arise;  thence  various  shades  of  functional  disturbance  arise, 
which  become  mingled  with  those  previously  existing. 

An  antecedent,  or  milder  stage,  usually  precedes  the  full 
development  of  encephalitis.  In  this  period,  which  ma}^  be 
called  that  of  congestion,  the  patient  is  disturbed  with  obstinate 
headache,  vertigo,  giddiness,  and  sometimes  difficulty  of  speech ; 
often  the  pupils  are  of  unequal  size;  the  face  is  alternately  red 
or  pale;  sometimes  there  are  spasmodic,  jerking  movements  of 
the  muscles  of  the  limbs,  face,  and  eyes;  sometimes  contractions 
and  strabismus;  there  may  likewise  be  disturbance  of  general 
sensation.  The  patient  may  have  the  feeling  of  formication  and 
heaviness  on  one  side  of  the  bodv. 


SYMPTOMS    OF    INFLAMMATION    OF    THE    BRAIX.  253 

The  symptoms  mentioned  gradually  augment  iu  intensity, 
and  the  disease  soon  appears  in  its  full  proportions.  In  a  few 
exceptional  cases  the  disease  assumes  the  form  of  apoplexy,  the 
patient  losing  entire  consciousness;  yet  usually  some  conscious- 
ness remains,  and  the  patient  is  capable  of  being  aroused.  The 
relaxation  of  the  body  is  incomplete,  and  the  limbs  do  not 
remain  wholly  motionless  and  passive.  Instead  of  passive 
relaxation  of  the  limbs  there  is  often  present  in  them  some  rigid- 
ity. In  fact,  such  stiffness  is  one  of  the  most  common  accom- 
paniments of  encephalitis.  This  rigid  state,  called  contracture, 
may  be  limited  to  a  small  number  of  muscles,  or  it  may  occupy 
one-half  of  the  bod}'.  Contracture  may  appear  primarily,  or  it 
may  be  preceded  or  accompanied  by  convulsions,  and  in  these 
cases  the  medulla  oblongata  is  probably  implicated  in  the  inflam- 
mation. The  convulsive  action  may  recur  rhythmically,  or  it  may 
assume  an  unmeasured  action  similar  to  chorea.  Paralysis  may 
affect  both  sides  of  the  body;  and  so  may  contracture.  Palsy  is 
seldom  seen  at  the  beginning  of  encephalitis. 

The  disturbances  of  intellect  present  endless  variety.  There 
may  be  only  a  slight  exaltation,  or  delirium  in  its  wildest  and 
most  acute  form  may  be  among  the  earliest  manifestations  of 
encephalitis.  The  mind  may  be  tormented  by  illusions,  in 
which  the  normal  sensory  impressions  are  wrongly  interpreted. 
There  may  be  hallucinations  of  sight,  hearing,  and  taste.  Faces 
and  objects  well  known  are  not  recognized,  and  familiar  things 
are  transformed  into  demons  and  other  objects  of  fear.  The  ear 
may  hear  sounds  which  are  wholly  imagined;  familiar  sounds 
may  be  transformed  into  those  which  are  humorously  unnatural, 
wildly  incongruous  and  monstrous.  There  are  deceptions  of  taste. 
The  patient  may  spit  from  his  mouth  what  he  conceives  to  be 
some  foul  or  unnatural  material.  And  the  sense  of  smell,  also, 
may  convey  false  messages;  that  is,  the  eye,  ear,  nose,  and  tongue 
may  carry  false  reports  from  their  respective  quarters.  In  short, 
the  unfortunate  subject  has  lost  all  natural  relation  to  his  sur- 
roundings, or,  summed  up  briefly,  the  acts  of  mentality  of  the 
subject  are  those  of  misinterpretation  or  falsification;  and  the 
conditions  in  some  way  or  another  are  similar  to  those  which 
the  alienist  would  name  insanity. 

There  is  an  increase  of  heat  in  the  commencement  of  enceph- 
alitis; the  heat  rarely  rises  above  103°  Fahr.  The  pulse  is  fre- 
quent, and  is  sometimes  unequal  and  irregular.  One  of  the 
earliest  and  most  constant  symjjtoms  of  commencing  encephalitis 


254  ENCEPHALITIS,    OR    INFLAMMATION    OF    THE    BRAIN. 

is  nausea  and  vomiting;  the  patient,  at  first,  vomits  any  materi- 
als which  may  have  been  recently  swallowed  ;  then  in  limited 
quantity  gastric  mucus  is  expelled,  and  soon  afterwards  bile  is 
vomited.  This  is  often  vomited  in  such  large  amount  that  it  is 
probable  there  is  some  connection  between  the  encephalic  inflam- 
mation and  the  generation  of  bile.  This  constant  vomiting  has 
a  tendency  to  augment  the  congestion  in  the  head  and  to  promote 
the  development  of  the  disease  there.  The  emptying  of  the  upper 
part  of  the  alimentary  canal,  by  lessening  the  content  there, 
becomes  the  cause  of  the  constipation,  which  is  a  constant 
accompaniment.  There  is  also  retention  of  urine;  the  inaction 
of  the  bowels  and  bladder  may  be  due  to  contracture  of  the  })arts, 
as  some  authors  have  suggested;  the  writer,  however,  thinks 
fsecal  and  uiinary  retention  is  rather  referable  to  the  patient's 
mental  perversion,  in  which  he  forgets  to  obey  the  summons  of 
functions  of  wdiich  the  accomplishment  in  normal  health  depends 
on  active  volition. 

The  primary  period  of  encephalitis,  of  which  the  leading 
features  are  excitation  and  increased  action,  is  succeeded  in  a  few 
days  by  depression.  The  excitable  and  acutely  active  mind 
becomes  obtuse  and  torpid;  vision  becomes  dull,  and  the  eye  is 
no  longer  annoyed  by  brilliant  light;  the  ear  scarcely  heeds 
sounds  and  is  no  longer  disturbed  by  those  which  previously 
pained  it;  and  so  the  other  senses  have  become  obtunded,  and  all 
have  fallen  asleep,  as  it  were,  at  tlie  portals  where  they  previously 
received  messages  for  the  mind. 

In  this  stage  the  patient  soon  falls  into  stupor;  there  is  both 
retention  and  incontinence  of  urine;  that  is,  the  palsied  bladder 
overflows  and,  instead  of  the  excessive  and  violent  movement  of 
the  muscles  which  required  force  of  nurses  to  prevent  the  patient 
from  injuring  himself,  he  becomes  partly  or  wholly  palsied;  the 
temperature  soon  rises  to  the  highest  abnormal  limits;  the  eyes 
and  face  are  suffused  with  redness  approaching  to  a  cj^anotic  tint. 
The  pulse  becomes  small  and  irregular;  the  breathing  lapses  into 
irregularity,  and  sometimes  it  is  temporarily  suspended.  The 
symptoms  named  precede  and  indicate  an  early  fatal  termina- 
tion. 

The  duration  of  the  disease  varies  greatly,  and  this  depends 
on  whether  or  not  the  disease  implicates  the  portions  of  the  brain 
which  are  speciall}^  the  centres  concerned  in  the  maintenance  of 
animal  life;  such  centres  are  found  in  a  limited  region  at  the 
base  of  the  brain,  and  particularly  include  the  medulla  oblongata. 


DIAGNOSIS    OF    INFLAMMATION    OF    THE    BRAIN.  255 

Life  may  continue  for  weeks,  as  the  author  lias  witnessed  several 
times,  when  the  inflammation  is  chiefly  limited  to  the  anterior, 
posterior  or  lateral  portions  of  the  brain.  On  the  other  hand, 
the  disease  may  run  a  rapid  course,  death  occurring  within  a  few 
days.  Encephalitis  may  have  a  uniform  course;  or  remissions  of 
intensity  and  moderation  may  alternate  with  each  other ;  also 
symptoms  of  depression  and  exaltation  may  be  concerned,  due  to 
gradual  involvement  of  parts  adjacent  to  the  j^rimary  focus  of 
inflammation,  and  then  the  disease  proceeds  in  such  a  manner 
that  the  inflammation  does  its  destructive  work  at  the  site  of 
commencement;  meanwhile,  in  contiguous  parts  it  is  in  process  of 
early  evolution.  In  this  condition  there  may  coexist  palsy  of 
some  muscles  and  spasmodic  movement  of  others;  or,  as  the 
author  has  seen,  there  may  be  irregular  motion  in  one-half  of  the 
body,  while  the  opposite  side  lies  in  passive  hemiplegia;  one  nupil 
may  be  contracted  while  the  other  is  dilated. 

The  disease  sometimes  has  a  chronic  development,  and  then 
its  changes  are  only  apparent  when  some  days,  or  perhaps  weeks, 
have  elapsed;  in  such  a  case  the  patient  emaciates;  there  is  occa- 
sional nausea,  and  food  is  ill  tolerated;  life  may  continue  thus 
for  months,  and  an  autopsy  finally  reveals  those  changes  in  the 
brain  which  are  produced  by  encephalitis;  probably  one  or  more 
foci  of  pus  may  be  discovered,  and  elsewhere  on  the  brain  cicatri- 
cial changes  may  be  found ;  since  here,  as  in  almost  ever}^  case  of 
morbid  action  which  continues  for  some  time,  a  close  inspection 
of  the  part  afl"ected  reveals  the  fact  that  there  has  been  an  attempt 
at  repair,  and  which  is  often  complete,  so  far  as  a  limited  portion 
of  the  affected  2:)art  is  concerned. 

Encephalitis  arising  from  a  traumatic  cause,  or  from  disease 
of  some  portion  of  the  cranial  wall,  remains  isolated  for  a  time; 
finally  pus  is  developed,  though  so  latently  that  it  may  not 
be  suspected,  if  it  does  not  involve  some  part  of  which  the  func- 
tional impairment  is  apparent;  yet  such  unsuspected  pus  after  a 
long  period  of  latency  may  burst  its  containing  walls  and  pass 
into  the  lateral  ventricles;  and  such  event  is  heralded  by  convul- 
sions, from  which  the  patient  sinks  into  a  coma,  which  may  be 
terminated  by  a  sudden  or  a  lingering  death. 

Diagnosis. — There  is  some  resemblance  between  encephalitis 
and  the  conditions  which  accompany  rupture  of  a  vessel  and 
softening  of  structure.  Yet  in  encephalitis  there  aj:e  signs  of  con- 
gestion early  in  the  disease  which  are  absent  in  the  other  two 
conditions.     There  is  always  an  augmentation  of  temperature  in 


256  ENXEI'IIALITIS,    OH    INFLAMMATION    OF    TIIF    BRAIN. 

an  inflamed  brain,  but  in  case  of  vascular  rupture  and  softening, 
the  temperature  does  not  rise,  but  it  may  sink  to  less  than  nor- 
mal. Contracture  is  more  frequent  in  encei)halitis,  and  it  often 
persists  for  some  time;  it  is  less  frequent  after  rupture  of  a  vessel. 
In  encephalitis  there  is  a  constant  progress  from  bad  to  worse, 
but  in  case  of  softening  and  vascular  rujiture,  there  often  occurs 
at  an  early  period  an  amendment  in  the  symptoms;  tolerance  of 
the  condition  is  frequently  seen.  "When  the  inflammation  is 
purely  meningeal,  the  temperature  rises  high,  and  the  functional 
disturbances  are  marked  by  more  acuteness  and  intensity  than 
is  the  case  in  simple  encephalitis. 

Pus,  the  result  of  an  encephalitis,  can  become  encysted  and 
then  remaiu  inert,  and  exert,  for  an  indefinite  time,  almost  no 
action  on  the  brain  ;  and  even  then,  should  it  suddenly  burst  and 
cause  apoplectic  symptoms,  the  true  nature  of  the  condition  could 
not  be  diagnosticated,  since  such,  apoplectic  attack  might  result 
from  a  tumor  encroaching  on  the  brain.  That  it  is  pus  might  be 
inferred  from  the  antecedents,  viz.,  if  there  had  been  an  otic  caries, 
or  one  about  the  orbit  or  nose,  then  there  would  be  satisfactory 
proof  that  pus,  and  not  a  neoplasm,  is  the  causal  agency. 

As  a  brief  summary  of  the  diagnostic  signs  of  encephalitis,  the 
following  may  be  oftered:  Temperature  abnormally  increased; 
acceleration  and  irregular  pulse;  pupils  contracted  or  dilated 
according  to  the  stage  of  the  disease;  twitching,  spasm  or  contrac- 
tion of  the  muscles,  and  perversion  or  alteration  of  mentality. 

From  the  author's  observation,  inflammation  of  the  brain  occurs 
much  oftener  in  the  male  tlian  in  the  female,  and  in  the  latter  the 
writer  has  seen  cerebral  and  hysterical  trouble  so  commingled  that 
it  was  impossible  to  arrive  at  absolute  definiteness  in  the  diagnosis. 
In  a  young  female  who  was  the  subject  of  hysteria,  he  saw  enceph- 
alitis suddenly  develop,  and  the  hysterical  symptoms  continued 
so  prominent  that  the  real  nature  of  the  disease  was  not  suspected 
until  it  had  nearly  reached  its  fatal  termination.  And  in  a 
second  case,  which  originated  in  mastoid  caries,  the  young  woman 
sank  into  fatal  coma  before  the  nature  of  the  disease  was  appre- 
hended. Hence,  to  the  conspectus  of  symptoms  just  presented 
should  be  added  the  precautionary  mention,  when  the  subject  is 
a  young  woman,  that  encephalitis  may  be  masked,  obscurely 
veiled  by,  or  commingled  with,  hysteria.  In  such  a  patient, 
elevated  temperature  would  indicate  the  cerebral  inflammation. 

Prognosis  infausta,  or  an  inauspicious  prediction,  may  be 
given  ill  respect  to  most  cases  of  inflammation  of  the  brain;  the 


TREATMENT    OF    IXFLAMMATIOX    OF    THE    BRAIN.  257 

inaccessibility  of  the  parts,  and  the  important  offices  which  they 
perform  in  the  maintenance  of  animal  life,  have  long  since,  even 
with  the  layman,  caused  this  inflammation  to  be  regarded  as  a 
]natter  of  the  greatest  peril.  Death,  as  a  rule,  is  the  end,  and 
should  the  case  not  terminate  in  death,  recovery  is  sometimes 
not  a  blessing  to  tlie  patient,  since  tliere  may  remain  some  per- 
version of  intellect,  of  the  power  of  motion,  or  of  special  and 
general  sensation.  Of  these  contingent  sequences  the  most  dis- 
astrous is  the  partial  or  complete  loss  of  intellect  wdiich  encepha- 
litis may  entail.  The  individual  ma}^  afterwards  remain 
changed  both  in  his  reason  and  in  his  emotional  nature;  and 
the  possibility  of  such  change  remaining  as  an  entailment  ren- 
ders life  of  little  value  to  the  patient. 

Treatment. — Encephalitis  may  end  by  resolution,  in  which 
there  is  complete  recovery,  the  effused  or  newly  formed  material 
being  wholl}^  removed  by  absorption;  or  the  disease  may  end  by 
absorption  of  some  of  the  material  effused  or  formed.  The 
structures  of  the  eucephalon  then  remain  somewhat  changed  from 
their  normal  condition.  There  are  alterations  slight  or  extensive, 
through  cellular  neoplasm ;  and,  thirdly,  the  new  formed  or 
effused  material  may  die,  a  condition  fatal  to  the  patient  in 
nearly  all  cases,  unless  relief  be  furnished  by  the  surgeon.  Of 
these  three  endings  the  first  is  the  desirable  one,  and  treatment 
to  accomplish  this  should  be  diligently  pursued.  The  elements 
which  inaintain  the  inflammation  and,  when  morbidly  changed, 
become  instrumental  in  destroying  the  patient's  life,  are  prima- 
rily derived  from  the  blood. 

The  indications  of  treatment  are  to  secure  resolution,  if  pos- 
sible, and,  failing  in  this,  to  avoid  the  fatal  ending  by  j^romoting 
and  obtaining  partial  absorption  of  the  material  which,  if  unre- 
moved,  destroys  life.  These  indications  are  fulfilled  by  lessen- 
ing the  supply  of  blood  to  the  brain.  The  patient  should  be 
Ijled  early,  freely,  and  to  the  utmost  limit  of  tolerance,  and  this 
abstraction  of  blood  should  be  done  with  the  lancet,  and  not  by 
leeching  or  cupping.  A  A^ein  in  the  arm  should  be  opened,  and 
while  blood  is  flowing  the  pulse  in  the  other  one  should  be 
observed,  and  the  flow  should  continue  until  the  pulse  becomes 
attenuated  and  feeble.  In  this  work  the  patient  should  have  the 
head  elevated,  so  that  if  signs  of  approaching  faintness  appear, 
the  head  can  be  lowered  and  syncope  averted. 

The  amount  of  blood  to  be  drawn  is  better  measured,  as  just 
said,  by  the  impression  on  the  pulse  than  by  the  amount  drawn. 


258         ENCErnAi.iTis,  ok  inflammation  of  the  bkain. 

Yet,  as  a  general  rule  in  the  rol)Ust  subject  of  full  habit  the 
withdrawal  at  one  bleeding  of  from  thirty  to  forty  ounces  is 
safely  borne.  If  this  is  followed  by  lowering  of  temperature, 
and  the  subsidence  or  disappearance  of  the  general  symptoms 
of  exaltation,  then  it  will  not  be  necessary  to  resort  to  depletion 
again,  since  there  is  a  fair  probability  that  the  inflammation 
has  been  overcome,  and  that  recovery  through  resolution  will 
ensue;  if  not  entire  resolution,  at  least  dispersion  of  so  niucli  of 
the  new-formed  material  that  the  remainder  will  be  tolerated. 
But  if  the  depletion  is  found  not  to  have  accomplished  this,  it 
must  be  repeated,  and  a  quantity  of  blood  again  removed  until 
an  impression  is  made  on  the  heart.  As  collateral  aids  in  com- 
bating encephalitis  are  cathartics,  sudorifics  and  diaphoretics. 
As  a  purgative  calomel  will  act  well;  so,  also,  the  saline  a})erients 
which  in  their  action  abstract  fluid  from  the  intestinal  wall.  As 
a  diuretic  and  alterative  the  iodide  of  potassium  acts  effectively. 
To  act  on  the  skin  pilocorpin  in  small  doses  may  be  used;  full 
doses  of  this  wonderful  agent  depress  the  heart  too  much. 
This  is  avoided  if  the  pilocarpinbe  given  in  doses  of  one-eighth  of 
a  grain,  repeated  every  eight  hours.  The  author,  in  accepting 
this  internal  medication  as  an  ally,  will  say  that  it  is  but  dust  in 
the  balance  when  weighed  against  venesection.  Internal  rem- 
edies may  be  likened  to  arrows  discharged  over  the  wall  of  a 
besieged  enemy,  which  fall  aimlessly.  But  venesection  acts  as 
does  the  besieger,  who  deprives  the  enemy  of  his  means  of  su.ste- 
nance,  and  in  so  doing  soon  conquers  him. 

But  this  treatment  may  fail  of  its  purpose.  The  inflammation 
then  ends  in  suppuration;  pus  is  developed  as  the  flnal  event  of 
the  encephalitis,  a  not  unfrequent  ending  of  the  disease,  wdiether 
of  traumatic  or  other  origin. 

If  pus  develops  as  the  result  of  a  traumatic  encephalitis  (the 
form  which  is  here  being  considered),  the  purulent  matter  may 
be  situated  between  the  skull  and  the  dura  mater,  between  the 
dura  mater  and  the  brain,  or  it  may  be  lodged  in  the  viscus. 
The  pus  may  be  collected  within  a  circumscribing  wall,  in  which 
there  seems  to  have  been  an  effort  on  the  part  of  nature  to  isolate 
the  morbid  matter  and  protect  the  adjacent  brain  from  it.  Or 
the  purulent  fluid  may  be  diff'used  and  widespread  as  a  thin 
stratum,  the  morbid  material  traveling  in  the  directions  in  which 
it  meets  the  least  obstruction.  The  pus  in  this  latter  form  is 
found  between  the  dura  mater  and  the  brain,  probably  because 
this  situation  is  more  favorable  for  diffusion.  The  anatomical 
conditions  here  are  unsuited  to  adhesion  and  occlusion. 


TREATMENT    OF    INFLAMMATION    OF    THE    BRAIN.  259 

Pus  situated  between  the  skull  and  dura  mater  is,  from  its  site, 
necessarily  small  in  amount.  It  is  commonly  but  imperfectly 
circumscribed.  The  color  is  greenish,  and  the  bone  over  it  has  a 
similar  tint  and  presents  the  first  signs  of  necrosis,  and  if  the 
case  has  continued  long,  the  bone  is  slightly  eroded.  Between 
the  dura  mater  and  the  brain  the  pus  is  yellowish,  and  is  closely 
adherent  to  the  membranes  subjacent.  But  if  the  purulent 
matter  be  developed  in  the  substance  of  the  brain,  such  collection 
is  circumscribed,  and  may  be  in  large  or  small  amount,  and  has 
the  characteristics  of  an  abscess.  Such  abscess,  which  may  be 
designated  cerebral  or  cerebellar,  according  to  its  site,  has  been 
seen  in  all  parts  of  the  brain;  and  when  in  the  cerebrum  it  may 
occupy  one  or  both  hemispheres;  and  in  this  situation  the  pus 
often  bursts  into  the  lateral  ventricles.  The  amount  has  been 
so  great  as  to  convert  one  hemisphere  into  a  capsular  envelope; 
or  it  may  occupy  the  upper  part  of  one  or  both  hemispheres,  and 
have  a  portion  of  the  cranial  vault  as  its  covering. 

As  stated  before,  the  desirable  ending  of  traumatic  encepha- 
litis is  resolution  complete,  or  nearly  so,  of  the  products  of  inflam- 
mation. The  worst  event  is  suppuration,  since  recovery  is  impos- 
sible without  evacuation  of  the  dead  material,  and,  though  this 
may  be  done  by  the  hand  of  nature,  yet  this  is  rare.  Art  may 
essay  to  do  it,  and  some  progress  has  been  made  in  this  direction 
since  modern  surgery  has  claimed  the  interior  of  the  skull  as  a 
field  for  legitimate  work.  Such  cases  unaided  have  recovered 
by  the  pus  finding  an  outlet  through  an  opening  formed  by  the 
fracture,  or  the  material  may  be  near  some  naturally  perforated 
portion  of  the  cranial  wall,  and  there  find  egress.  Thus  through 
an  opening  occupied  by  an  emissary  of  Santorini,  in  the  parietal, 
frontal  or  temporal  region,  pus  may  find  a  path  for  emergence. 
Again,  such  pus  lying  near  the  base  of  the  skull,  as  the  result  of 
counter  blow,  may  be  so  imprisoned  that  neither  surgical  art 
with  its  daring  nor  nature  with  her  resources  can  find  a  way  of 
escape. 

The  presence  of  pus  may  be  suspected  where,  despite  the 
active  antiphlogistic  treatment  above  detailed,  outward  symp- 
toms still  continue;  where  there  remains  perversion,  either  in 
the  form  of  exaltation  or  depression  of  intellect,  motion  or  sen- 
sation. Symptoms  of  depression  are  the  more  usual,  viz.,  mental 
torpor.  Muscular  paresis  or  j)alsy,  or  anaesthesia,  or  parsesthesia 
of  some  organ  of  the  body,  points  to  central  trouble,  probably 
from  pressure  due  to  a  collection  of  j^us.  A  significant  symptom 
is  a  rigor  and  continued  high  temperature. 


260         l:n'ci:i'ha LITIS,  uii  inflammation  of  the  kkai::. 

If  these  symptons,  one  or  ull,  are  })re.seiit,  the  presence  of  i)us 
may  be  inferred  with  sutticient  probaJjihty  to  justify  the  use  of 
the  trephine  or  some  procedure  by  which  the  material  may  be 
evacuated,  and  here  two  classes  of  cases  present  themselves  :  one 
in  which  the  causal  agency  has  been  a  fracture,  and  another  in 
which  llie  causal  violence  did  not  break  the  bone. 

Where  a  fracture  exists  and  is  of  such  a  character  as  to  expose 
the  dura  mater,  tlie  condition  of  the  latter  may  clearly  point  to 
the  existence  of  pus  near  by;  thus  a  brown,  ashy  or  semi-necrosed 
appearance  denotes  lowered  or  vanishing  vitality,  and  tlio  |»roba- 
bility  of  pus  near  by,  and  warrants,  if  the  foregoing  general 
symptoms  be  present,  the  opening  of  the  dura  mater,  and  if 
purulent  matter  does  not  lie  contiguous,  the  cortical  layer  of 
the  brain  should  be  explored  by  means  of  a  small  trocar;  and  if 
pus  be  thus  detected,  the  overlying  structure  must  bo  freely 
opened,  and  the  dead  material  washed  out  by  gentle  irrigation; 
and  this  irrigation  may  be  repeated  until  pus  no  longer  appears. 

In  the  second  case  in  which  fracture  is  absent,  and  yet  the 
general  symptoms  point  to  localized  purulent  material,  an  effort 
must  be  made  to  discover  and  evacuate  it.  For  this  purpose  at 
the  site  of  injury  the  scalp  should  be  incised  and  the  bono 
examined.  As  intra-cranial  extravasation  of  blood  when  next 
to  the  wall  reveals  itself  by  alterations  in  the  pericranial  lining, 
so  changes  occur  in  this  membrane  when  pus  lies  directly  under 
the  intermediate  wall;  for  example,  if  the  pericranium  be  dis- 
colored or  is  detached  from  the  bone,  then,  beneath  such  site, 
pus  is  probably  located.  Also,  along  with  looseness  of  membrane 
there  will  be  discoloration  of  the  bone  itself;  the  latter  will  be 
brown  instead  of  a  pinkish  hue;  such  bone  will  be  in  the  first 
stage  of  necrosis.  In  such  conditions  of  the  cranial  wall  and  its 
investing  membrane,  the  trephine  should  be  used,  and  a  free 
opening  made;  and  should  pus  then  not  be  in  view,  an  incision 
should  be  made  into  the  cortical  stratum  of  the  brain;  and  if 
pus  be  discovered,  the  treatment  should  be  similar  to  that  pur- 
sued in  the  case  of  an  opening  made  by  fracture.  Also  should 
there  be  a  fissuj'e  in  the  wall  without  other  visiljle  changes,  the 
trephine  should  be  used  at  that  point. 

There  is  another  class  of  cases  in  which  the  surgeon  is  nearly 
or  quite  without  guide;  here  there  is  no  lesion  or  change  discov- 
erable in  tlie  soft  parts,  and  the  cranial  wall  jiresents  no  abnormal 
appearance;  in  such  there  is  no  guide  for  the  localization  of  the 
pus  except  that  the  patient  received  a  severe  blow  at  some  point 


TUMORS.  261 

of  his  skull,  and  subsequently  symptoms  of  suppuration  have 
J) resented  themselves.  In  this  case,  though  the  pericranium  and 
skull  be  found  intact,  yet  in  the  existing  state  the  surgeon  should 
resort  to  a  procedure  similar  to  acupuncture  exploration.  For 
this  purpose  a  small  incision  is  first  to  be  made  through  the 
scalp ;  then  an  opening  is  made  through  the  bone  by  means  of  a 
small  drill;  through  this  canal  a  small  trocar  can  be  passed,  and 
the  pus,  if  present,  is  thus  detached.  Should  nothing  be  found 
when  the  dura  mater  is  pierced,  then  the  instrument  should  be 
passed  into  tlie  superficial  or  even  deeper  structure  of  the  brain. 
Should  no  purulent  material  be  found  at  the  point  first  chosen, 
then  another  aperture  should  be  drilled  near  by,  and  then  another, 
until  pus  has  been  discovered,  or  the  search  for  it  proved  fruit- 
less. If  the  pus  be  thus  located,  then  a  larger  opening  should  be 
made  with  the  trephine,  and  the  work  of  emptying  and  irrigat- 
ing be  done,  in  the  manner  before  described.  If  the  exploratory 
procedure  here  described  be  done  with  aseptic  precautions,  should 
one  fail  to  find  pus,  the  injury  to  the  parts  will  not  be  a  serious 
one. 

Tumors. — When  the  brain  is  studied  in  its  earliest  stage  of 
development,  it  is  found,  according  to  the  observation  of  embry- 
ologists,  to  originate  in  the  epiblastic  layer  of  the  embryo.  In 
accordance  with  such  derivation  one  might  expect  that  neoplasms 
originating  here  would  conform  in  type  to  those  originating  in 
the  cutaneous  tissue;  and,  hence,  an  epithelial  neoplasm  might 
be  inferred  to  have  its  origin  here.  In  the  great  changes  which 
this  epiblastic  structure  passes  through  to  become  brain,  the  latter 
seems  to  inherit  in  a  slight  degree  the  tendencies  to  neoplastic 
perversion  which  are  prevalent  in  the  surface  of  the  body. 

Tumors  of  both  the  malignant  and  benign  type  are  found  in 
the  encephalon.  As  examples  of  the  malignant  type  there 
develop  here,  carcinoma,  sarcoma  and  glioma.  These  growths, 
when  they  originate  in  the  brain,  proceed  oftenest  from  the 
cortical  structure. 

Carcinoma  may  have  its  primary  origin  in  the  surface  of  the 
brain,  in  the  dura  mater,  or  it  may  arise  from  the  inner  face  of 
the  skull,  and  the  growth,  springing  froin  any  of  these  sites, 
generally  develops  centrally  and  excentrically.  It  may  attain  a 
great  size. 

Sarcoma  occurs  more  rarely  than  carcinoma;  in  its  mode  of 
growth  it  is  similar  to  cancer. 

Glioma  may  be  characterized  as  less  heterotopic  or  foreign,  in 


262         ENCEPTiALrns,  or  inflammation  of  the  bkain. 

its  site  liere,  tliun  cancer  or  sarcoma;  for  its  stroma  is  analogous 
to  the  skeleton  tissue  of  (he  brain.  It  consists  of  a  thin  Aveb-like 
tissue  iu  which  the  constituent  cells  are  contained,  and  the 
whole  is  remarkable  for  its  softness  and  fragility;  an<l,  owing  to 
this  want  of  firm  union  of  its  elements,  the  glioma  is  subject  to 
rupture  and  effusion  of  blood.  Glioma  sometimes  contains  fusi- 
form cells,  and  then  the  growth  is  called  glio-sarcoma. 

The  benign  growth  is  rarely  met  with  in  the  cranial  cavity. 
Examples  of  this  are  the  psammoma,  the  lipoma,  and  the  angioma 
and  dermoid  growth. 

The  psammoma  arises  almost  always  from  the  dura  niater. 
It  is  constituted  of  particles  of  sand  connected  together  by  lilms 
of  connective  tissue.  The  tumor  resembles  a  mulberry  in  its 
surface,  and  may  attain  the  dimensions  of  a  small  walnut. 

The  li})oma  is  rare  here;  yet  it  has  been  found  at  sites  where 
there  is  normally  a  small  amount  of  adipose  tissue.  Such  sites 
are  the  optic  chiasm,  the  pons  A''arolii  and  the  raphe  of  the 
corpus  callosum. 

Ansfioma  is  found  in  the  cranial  cavity;  it  does  not  ])resent 
itself  in  a  form  that  would  demand,  or  be  suitable  for,  intra- 
cranial intervention.  Should  surgical  treatment  be  required,  the 
better  plan  would  be  to  ligate  the  common  carotid  supplying 
blood  to  the  tumor. 

A  case  of  dermoid  tumor  situated  in  the  anterior  portion  of 
the  brain  was  discovered  in  a  necropsy  made  in  one  of  the  hospi- 
tals of  San  Francisco.  Hair  and  other  components  of  the 
dermoid  tumor  were  found. 

Syphiloma. — The  syphilitic  or  gummy  tumor  appears  within 
the  cranium  as  the  product  of  constitutional  syphilis.  This 
growth  may  arise  from  the  dura  mater,  pia  mater  and  the  struc- 
ture of  the  brain. 

Secondary  syphilis  may  appear  either  on  the  outer  or  tlie 
inner  surface  of  the  dura  mater.  When  on  the  external  side  it 
appears  as  a  slow  inflammatory  process,  whence  there  is  a  growth 
of  bone,  an  osteoma  of  small  or  large  extent.  But  the  syphiloma 
proper  arises  from  the  inner  face  of  the  membrane  and  grows 
toward  the  brain,  and  may  attain  dimensions  varying  from  that 
of  a  filbert  nut  to  that  of  a  walnut.  Such  growth  may  encroach 
on  a  vessel  and  then,  obstructing  the  flow  of  blood,  it  may  cause 
softening  or  atrophy  of  a  limited  region  of  the  brain.  Or  it  may 
encroach  on  a  nerve  in  its  course,  or  it  may  lessen  the  diameter 
of  a  foramen,  and  in  each  case  the  function  of  the  nerve  is  altered 


SYMPTOMS    OF    IXTRA-CKAXIAL    TUMOR.  263 

or  abolished.  The  growth  may  arise  from  the  pia  mater,  and 
produce  troubles  similar  to  those  just  mentioned.  And  finally, 
the  gummy  tumor  may  originate  in  tlie  tissue  of  the  brain  itself 

The  syphiloma  is  of  a  grayish  red  color,  and,  on  section,  its 
interior  presents  yellowish  spots;  these  have  originated  in  caseous 
change  of  the  growth.  AVhen  in  the  brain  the  growth  is  often 
surrounded  by  a  layer  of  translucent,  colloid  material.  The 
growth  may  become  casefied,  a*nd  is  then  fragile;  or  it  may 
become  dense  and  resistant  in  structure,  and  become  surrounded 
by  a  cyst-like  membrane. 

The  gummy  growth  is  most  often  found  at  the  base  of  the 
brain,  generally  contiguous  to  the  sella  turcica,  and  then  by 
jjressure  on  the  optic  nerve,  or  on  the  motor  nerves  of  the  eye, 
such  growth  is  the  occasion  of  some  phase  of  impairment  of  the 
visual  apparatus.  Besides  being  an  agent  of  compression,  the 
growth  awakens  inflammatory  action,  and  thus  localized  paresis 
and  excitation  may  coexist. 

A  growth  having  some  analogy  to  the  syphiloma  is  one  in 
which  the  constituent  material  is  tubercular  matter;  in  situation, 
aspect  and  form  the  two  are  similar.  Yet  the  external  manifesta- 
tions which  accompany  such  growths  are  entirely  different,  for  in 
the  one  case,  the  rashes  of  s^^philis  are  present;  in  the  other,  the 
symptoms  of  tuberculosis  present  themselves  in  some  other  part 
of  the  bod}';  and  the  tubercular  bacillus  may  be  found. 

Osteoma  and  chondroma  may  develop  from  the  inner  surface 
of  the  cranium  and  cause  trouble  through  pressure  on  the  brain 
or  encroachment  on  nerves  arising  from  it.  Exceptionally,  the 
osteoma  has  been  seen  to  spring  from  the  inner  face  of  the  dura 
mater,  also  from  the  surface  of  the  brain  itself. 

Parasitic  growths  occur  within  the  cranial  cavit}-;  the  content, 
then,  may  be  cysticerci  or  the  echinococci.  The  cysticercus  cyst 
may  be  situated  in  the  central  or  superficial  parts  of  the  brain;  it 
occurs  oftenest  in  the  convolutions.  Such  cyst,  in  multiple  form, 
is  found  also  in  other  parts  of  the  body.  The  echinococcus  cyst 
is  f  jund  in  or  on  the  hemispheres,  commonly  but  one  or  two  in 
number.  The  parasitic  cyst  can  attain  the  volume  of  a  pigeon's 
egg.  These  cystic  growths  may  cease  to  grow  and  their  jDarasitic 
inhabitants  die,  and  the  content  undergo  fatty  metamorphosis. 

Symvptoms  of  Intra- cranial  Tumor. — The  location  of  an  intra- 
cranial tumor  is  a  pathological  problem  which  is  often  extremely 
difficult  of  solution;  in  fact,  large  tumors  have  existed  without 
having  been  suspected,  and  were  only  discovered  by  necropsy. 


20-1  EN'CKrilA  LITIS,    ()U    INFI.AMMATIdN    OF    TIIK    I5RAIX. 

And  this  may  occur  for  the  reason  that  certain  enceplialic  struc- 
tures are  liighly  tolerant  of  invasion,  whether  this  be  from  a 
growth,  efiused  blood,  or  an  abscess;  such  tolerance  is  possessed 
by  tlie  white  structure  in  the  commissures,  and  in  the  interior  of 
tlie  hemispheres.  Tumors  located  at  the  base  of  the  skull  are 
distinguished  from  those  arising  at  the  sides  or  summit  of  the 
brain  through  causing  functional  disturljance  of  some  of  the 
nerves  which  arise  from  the  base.  Where  indications  of  basial 
tumor  are  present,  and  yet  there  is  no  peripheral  index  of  exact 
location,  then  among  the  possible  sites  which  maybe  suspected 
is  one  near  the  body  of  tlie  sphenoid  bone,  since  the  structures 
reposing  on  its  intra-cranial,  as  well  as  its  pharyngeal  surface,  in 
their  primary  development  undergo  great  moi-i)hological  trans- 
formation; and  if  located  here  the  tumor  would  lie  beyond  the 
surgeon's  reach.  Tlie  writer  is  pleased  to  state  that  with  the 
light  which  has  been  furnished  by  the  recent  revision  of  the 
chapters  of  neurology,  the  surgeon,  aided  by  the  physician,  can 
often  locate  the  intra-cranial  tumor,  and,  if  it  be  anatomically 
accessible,  he  is  able  to  penetrate  to  and  to  remove  it. 

A  general  character  of  neoplasms  of  any  type  whatsoever, 
located  in  the  skull,  is  slow  and  irregular  growth,  and  sudden  or 
})aroxysmal  appearance  of  the  morbid  phenomena  produced  by 
the  growth.  Such  irregularity  in  morbid  movement  is  referred 
to  the  appearance  and  disappearance  of  local  congestion.  In 
some  instances  the  volume  of  the  growth  may  lessen,  as  has 
occurred  with  the  syphiloma. 

The  intra-cranial  tumor  is  the  cause  of  functional  trouble  aris- 
ing from  lesion  or  disturbance  of  the  parts  primarily  compressed 
or  acted  on;  ixUo  from  disturbance  of  parts  adjoining;  and,  lastly, 
functional  alteration  in  peripheral  structures.  This  functional 
disturbance  appears  in  different  forms;  examples  of  it  are  spas- 
modic contractions,  convulsion,  augmented  sensation,  delirium, 
febrile  reaction,  localized  palsy  and  coma.  These  SNanptoms  are 
classifiable  under  two  heads:  excitation  from  increased  supply  of 
blood,  and  depression  from  anoemia  due  to  compression  caused  by 
the  growth.  These  phenomena  usually  occur  in  the  order  here 
described;  yet  there  are  many  exceptions;  symptoms  of  excita- 
tion and  depression  may  be  commingled,  here  due,  probably,  to 
multiple  development;  a  large  growth  may  compress  parts,  while 
another  is  in  its  initial  period  of  evolution  ;  and  a  single  large 
tumor  may  compress  subjacently  and  adjacently;  it  may  cause 
an  alilux  of  blood,  and  thus  spasmodic  contraction  and  par- 
alysis may  coexist  in  adjacent  peripheral  parts. 


SYMPTOMS    OF    INTRA-CEANIAL    TUMOR  265 

The  s^niiptoms  caused  by  intra-cranial  tumor  are  not  exactly 
alike  in  any  two  cases ;  the  resemblances  are  only  general.  The 
most  common  symptom  is  headache,  which  may  be  diffused  over 
tlie  whole  head,  or  it  may  be  local,  and  when  confined  to  the  occip- 
ital region  the  lesion  is  probably  cerebellar.  It  may  be  so  acute 
as  to  awaken  cries  of  anguish  when  intensified  by  sound,  light, 
movement  or  vomiting.  As  a  great  part  of  the  structure  of  the 
brain  is  insensible,  the  cephalalgic  pain  must  be  referred  to  lesion 
of  the  dura  mater,  of  the  crura  and  the  pons  Varolii.  In  such 
condition  the  patient  is  restless,  peevish  and  easily  awakened  to 
anger;  it  is  with  difficulty  that  he  sleeps  and,  when  he  does  so,  he 
is  disturbed  by  frightful  dreams. 

Another  common  symptom  is  vertigo,  arising  from  changes 
in  the  position  of  the  body,  in  which  the  head  is  raised  or  lowered. 
In  such  vertigo  the  patient  imagines  that  objects  about  him  are 
whirling  around  him;  or  when  lying  on  his  bed,  as  in  a  case  seen 
by  the  author,  the  subject  fears  that  he  wall  fall  upwards,  and  to 
avoid  doing  so,  he  clings  violently  to  his  bed.  In  walking,  the 
patient  may  suddenly  become  worse,  and  he  may  fall  or  be  forced 
to  support  himself  against  a  wall  or  other  object. 

Singular  sensations  are  felt  in  the  head;  the  patient  fancies  it 
will  burst  or  that  it  is  filled  with  fluid  that  moves;  one  patient 
had  the  feeling  that  his  head  was  filled  with  bran. 

These  symptoms  are  usually  concurrent  with  impaired  intel- 
lect ;  if  an  intelligent  patient,  he  observes  that  he  thinks  more 
slowdy  and  with  more  difficulty  than  he  formerly  did;  the  atten- 
tion can  scarcely  be  fixed;  facts  committed  to  memory  are  incor- 
rectly recalled ;  for  example,  the  multiplication  table  or  prose  or 
verse  once  learned  is  inaccurately  recalled.  This  clouded  condi- 
tion gradually  merges  into  indistinct  twilight  of  intellect,  and  this 
again  into  total  mental  darkness;  oblivion,  in  which  the  subject 
divested  of  any  psychical  endowment  lies  in  a  torpid  condition, 
with  rectal  and  vesical  incontinence. 

Another  symptom  of  such  tumor  is  vomiting,  which  occurs 
when  the  stomach  is  full,  and  if  empty,  there  is  retching ;  assum- 
ing the  erect  position  may  arouse  such  action,  which  subsides 
when  the  subject  is  recumbent.  Such  is  the  case  when  the  tumor 
presses  on  the  cerebellum  or  the  crura  cerebelli. 

Encephalic  tumor  at  an  early  stage  may  cause  epileptiform 
convulsions,  which  may  come  on  instantaneously  and  cause  the 
patient  to  fall.  These  attacks  may  recur  often,  and  soon  end 
life.  Such  convulsions  appearing  in  the  adult  without  other 
assignable  cause  should  awaken  the  suspicion  of  tumor. 
IS 


2G0  KXCEIMIALITIS,    Oil    INFLAMMATION'    OF    TIIK    F.KAIN. 

Limited  contracture  and  localized  bypersesthesia,  continued 
or  recurrent,  are  symptomatic  of  encephalic  tumor.  The  most 
unerring  indication,  however,  is  disturbed  function  of  cranial 
nerves,  especially  when  tliis  is  associated  with  hemiplegia. 
Physiological  exploration,  which  in  recent  years  has  been  so 
diligent  in  its  work,  has  discovered  that  the  cranial  nerves  have 
a  cerebral  as  well  as  a  nuclear  origin.  The  nuclear  origin  is 
from  a  nucleus  situated  in  the  floor  of  the  fourth  ventricle,  or  in 
the  pons  Varolii.  In  this  respect  these  nerves  are  so  similar 
that  a  description  of  the  facial  nerve  will  serve  for  the  history 
of  the  whole.  Primarily,  it  may  be  stated  that  this  nerve  may 
be  palsied  by  })ressure  on  the  same  side  as  the  palsy  is;  or  this 
pressure  may  be  on  the  side  opposite  to  that  of  tiie  palsy,  as 
herewith  is  explained. 

The  facial  nerve,  having  entered  thebulb  of  the  cord,  proceeds 
to  a  nucleus  located  on  the  surface  of  the  fourth  ventricle  where 
the  bulb  is  just  entering  the  pons;  above  and  beyond  the  nucleus 
a  radicle  in  the  form  of  a  band  passes  upwards  into  the  brain. 
As  is  known,  a  tumor  pressing  on  some  part  of  a  hemispliere 
causes  hemiplegia  on  the  side  of  the  body  opposite  to  the  com- 
pressed hemisphere;  and  meanwhile  the  cerebral  branch  of  the 
facial  nerve  may  be  so  implicated  that  there  will  be  palsy  of  the 
face  on  the  same  side  as  the  general  hemiplegia.  But  a  tumor 
acting  on  the  facial  nerve  beyond  its  nucleus,  causes  palsy  on  the 
.same  side  as  that  on  which  the  pressure  is  made.  Thence  it 
results  that  wlien  multiple  tumor  exists  there  may  be  hemiplegia 
on  one  side  and  facial  palsy  on  tiie  other.  It  has  been  found  that 
pressure  on  the  cerebral  radicle  of  the  facial  causes  much  less 
palsy  than  when  the  pressure  is  on  the  nerve  near  or  beyond  the 
nucleus;  and  such  limited  facial  palsy  concurring  with  a  hemi- 
plegia would  indicate  that  the  site  of  the  tumor  is  in  the  cerebral 
or  superior  portion  of  the  .skull;  but  a  facial  palsy  on  the  side 
opposite  a  hemiplegia  might  denote  multiple  tumor,  one  above, 
and  one  near  the  base  of  the  skull  pressing  on  the  facial,  and 
which  is  situated  on  the  same  side  as  the  tumor  above. 

Several  cranial  nerves  are  often  implicated  at  the  same  time, 
and  as  each  has  .a  nuclear  origin,  the  resultant  paralysis  will 
obey  tlie  laws  just  mentioned  as  obtaining  in  the  case  of  the 
facial.  Vision  is  often  disturbed  b\''  an  intra-cranial  tumor,  and 
such  a  symptom  would  be  perceived  by  the  patient  at  an  early 
stage.  A  tumor  acting  on  the  tubercula  qiiadrigemina  may 
cause   partial  or  entire  blindness.     Pressure  on  the  cerebellum 


TREATMENT    OF    INTRA-CEAXIAL    TUMOR.  267 

causes  feeble  vision ;  for  this  no  explanation  lias  been  given. 
The  auditory  nerve  may  be  acted  on,  yet  impaired  hearing  is 
seldom  thus  caused ;  more  often  there  is  awakened  some  sub- 
jective sensation,  such  as  ringing,  roaring,  buzzing,  etc.  The 
sense  of  smell  is  seldom  disturbed  by  an  intra-cranial  growth. 

In  some  cases  the  encephalic  tuuior  does  not  impair  the 
nutrition  of  the  patient;  he  may  even  improve  in  flesh.  On  the 
contrary,  should  there  be  nausea,  vomiting  and  other  depress- 
ing conditions,  the  subject  may  become  emaciated.  If  the  tumor 
be  cancerous  in  nature,  then  the  usually  attendant  cachexy  may 
soon  appear,  and  greatly  reduce  the  patient's  body. 

The  tumor  may  perforate  the  cranial  wall,  and  then  it  usually 
makes  its  appearance  through  one  of  the  natural  openings  of 
the  skull,  as  at  the  orbit,  or  the  upper  part  of  the  nasal  fossae; 
or  it  may  perforate  the  wall  and  uplift  the  scalp.  Such  perforat- 
ing tumor  may  be  hard  or  soft.  The  protruding  portion  mny 
pulsate  with  the  pulse,  and  sometimes  it  rises  with  expiration. 
If  pressed  on,  coma  may  result.  The  appearance  of  tlie  tumor 
through  the  cranial  wall  is  attended  by  diminution  of  compres- 
sion and,  lience,  an  amelioration  of  the  symptoms  caused  by 
compression. 

The  course  of  intra-cranial  tumor  is  usually  of  long  duration, 
and  it  is  characterized  by  remissions,  accessions,  and  exaggera- 
tions of  the  symptoms ;  a  course  in  which  there  is  an  absence  of 
uniformity.  Death  comes  in  many  cases  from  palsy  of  the 
medulla  oblongata. 

The  prognosis  is  extremely  unfavorable;  the  greater  number 
of  intra-cranial  tumors  end  fatally;  the  exception  is  where  the 
tumor  is  of  syphilitic  origin.  Tumor  from  this  cause,  in  its 
early  stage,  if  not  curable,  at  least  is  controllable.  The  can- 
cerous and  aneurysmal  tumors  destroy  life;  yet  the  time  in  which 
the  tumor  does  its  fatal  work  depends  greatly  on  its  site.  The 
rule  concerning  this  is  that  growths  located  in  the  upper  part  of 
the  cranial  cavity  are  tolerated  much  longer  than  those  in  the 
base.  A  tumor  pressing  on  the  medulla  oblongata,  or  the  pons 
Varolii,  does  its  fatal  work  swiftly.  The  prognosis  of  the  syphi- 
litic tumor,  if  the  case  be  seen  early,  is  favorable;  but  if  the 
syphiloma  be  allowed  to  develop  without  treatment,  it  encroaches 
on  and  occasions  lesions  of  the  contiguous  parts,  which  sometimes 
are  irreparable. 

Treatment. — Until  recently  the  intra-cranial  tumor  was  com- 
bated   chiefly  by  internal  medication,   and   this  treatment  was 


268  ENCEPHALITIS,    OR    IXFI.AMMATION"    OF    THE    BRAIN'. 

limited  to  remedies  which  merely  relieved  syra[)toms,  and 
mainly  that  of  pain.  Pain  was  controlled  by  the  use  of  opium 
and  other  narcotics.  Treatment  which  aimed  at  a  cure  or 
removal  of  the  cause  was  only  pursued  with  hope  wliere  the 
growth  originated  from  constitutional  s^'phihs. 

To  relieve  the  headache  morphia  in  a  third  of  a  grain  doses 
should  be  given  and  repeated  every  six  hours,  or  in  larger  doses 
if  the  dose  mentioned  does  not  give  relief.  The  alkaloid  of 
hyoscyamus  may  be  used,  viz.,  one-sixtieth  of  a  grain  of  hyos- 
cyamine  may  be  injected  hypodermically;  thus  sleep  may  be 
obtained  when  morphia  fails.  Atropine  in  similar  amount  may 
be  used  hypodermically.  Aconite  may  be  used ;  the  fluid  extract 
may  be  used  externally,  or  an  ointment  or  solution  of  the  alka- 
loid aconitine.  A  weak  solution  of  the  cyanide  of  potassium 
may  be  used  externally  over  the  focal  point  of  pain.  The  head- 
ache may  be  palliated  by  tlie  local  use  of  ice.  As  anodyne  rem- 
edies these  maybe  administered  :  the  bromide  of  potassium  and 
the  tincture  of  gelsemium. 

As  mentioned  before,  the  only  hope  of  curing  by  internal  med- 
ication is  where  the  tumor  is  the  product  of  syphilis.  Here  the 
administration  of  the  protiodide  of  mercury,  one-half  grain  three 
times  daily,  will  not  only  arrest  the  development  of  a  syphiloma, 
but  favor  its  absorption.  With  this  agent  the  writer  has  obtained 
the  most  satisfactory  results;  intellect  on  the  verge  of  imbecility 
has  been  restored  to  normal  state;  a  staggering  walk  has  been 
changed  to  a  steady  gait,  and  vertigo  relieved.  Tlie  remedy, 
however,  must  be  commenced  as  early  as  the  cephalic  sj^mptoms 
manifest  themselves.  For  the  same  purpose  Hydrargyrum 
cyanuretum  may  be  used  with  benefit.  To  use  this,  prepare  a 
solution  as  follows : — 

R.  Aqua? 51 

Hydrargyri  cyanureti gr  x 

Misce. 

Inject  this  nypodermically,  commencing  with  five  drops, 
and  increase  the  dose  to  ten  drops.  Ten  drops,  the  maximum 
dose,  will  contain  about  one-sixth  of  a  grain  of  the  salt.  This 
compound  of  mercury  has  been  found  by  the  writer  to  act  more 
efficiently  than  any  other.  The  gummy  nodule  in  iritis  is  sure 
to  literally  melt  away  before  this  treatment,  and  in  case  the  tumor 
be  cancerous  this  treatment  promises  some  relief  in  retarding 
growth.  The  writer  has  verified  that  this  is  so  in  cancerous 
growths  seated  on  the  surface  of  the  body. 


TKEATMEXT    OF    INTRA- CRAXIAL    TUMOR.  269 

As  known,  within  the  last  few  years,  surgery,  emboldened  by 
the  success  attained  by  the  antiseptic  method,  has  invaded  regions 
liitherto  untouched  by  instrument;  the  cranial  cavity  is  fearlessly 
laid  open,  and  disease  once  impregnably  entrenched  there,  is 
exposed,  attacked,  and  sometimes  removed;  it  must  be  said  with 
some  reserve,  sometimes,  since  surgical  aggression  here  has  more 
often  been  attended  by  defeat  than  success.  Yet,  when  the  fatal 
character  of  the  intra-cranial  neoplasm  is  considered,  great  risk 
in  the  adventure  is  justifiable;  and  should  failure,  coupled  even 
with  the  death  of  the  patient,  be  the  result,  it  may  be  reckoned 
as  a  gain  to  the  sufferer;  for  what  human  being  would  not  prefer 
death  to  life  coupled  with  dementia? 

The  rule  of  procedure  should  be  to  first  determine  whether 
the  growth  is  so  located  as  to  be  accessible;  namely,  if  at  the 
summit  or  the  sides  of  the  brain,  it  can  be  reached  b}'-  means  of 
the  trephine,  saw,  chisel  and  mallet.  Or,  as  a  preliminary,  the 
wall  may  be  opened  by  the  exploratory  drill  mentioned  before, 
and  a  small  section  of  the  subjacent  soft  part  withdrawn  and 
examined  microscopically.  Guides  to  location  are  to  be  found  in 
the  affection  of  speech,  motion  and  sensation.  By  means  of  the 
saw,  sections  of  the  wall  may  be  uplifted  on  a  large  scale;  and  the 
dura  mater  being  opened,  the  surface  of  the  brain  can  be  seen, 
and  a  neoplasm  discovered,  can  be  removed;  and  the  growth 
being  extracted,  the  uplifted  osseous  bridge  can  be  lowered  to  its 
former  site.  Should  the  growth  be  a  cyst,  or  benign  in  nature,  it 
would  be  possible  to  thus  cure  the  patient.  Where  the  growth 
lie^  in  contact  with  the  base  of  the  skull,  that  is,  springs  from  the 
inferior  surface  of  the  brain,  conservation  would  pronounce  the 
word  inaccessible.  This  warning,  however,  is  quite  uu heeded  by 
the  gens  audax  omnia  perpeti;  for  example,  by  such  as  announce 
that  they  think  operations  for  the  removal  of  tumors  from  the 
base  of  the  brain  are  feasible ;  such  daring  characterized  a  special- 
ist in  cerebral  surgery,  whom  the  writer  heard  say  that  he 
believed  it  possible  to  so  open  the  skull  and  lift  up  the  brain  as 
to  catch  a  view  of  the  foramen  magnum.  The  reader  may  ask, 
Did  he  mean  this  of  the  living  subject?  The  well-known  ineffi- 
ciency of  medicine  against  these  growths  in  nearly  all  cases,  has 
lured  on  the  surgeon's  hand,  and  encouraged  and  emboldened 
work  here  which  elsewhere  should  not  be  permitted.  For  death 
is  a  cheap  price  with  which  to  purchase  exemption  from  helpless 
palsy  and  hopeless  amentia. 

The  operative  course  advised  by   Horsley,  Macewen,   Keen, 


'2,0  EXrKI'HALITIS,    OK    INFLAMMATION    OF    TIIK    BRAIN. 

Laiiphearaiid  others  to  be  pursued  in  the  removal  of  a  ineuingeal, 
cerebral  or  cerebeHar  growth  is  to  select  the  part  towards  which 
the  diagnostic  indices  point  convergingly,  and  there  to  remove, 
by  means  of  the  trc[)iiine,  saw  and  chisel,  enough  of  the  cranial 
wall  to  reach  and  uncover  the  tumor;  and,  liaving  exposed  the 
arowth  and  determined  the  connections,  the  surgeon  continues 
with  the  removal,  at  which  w^ork  vessels  must  be  avoided  or 
ligated  if  they  be  opened.  Macewen  fearlessly  attacks  the  dural 
sinuses;  and  finally  the  wound  made  in  the  scalp  and  dura 
mater  must  be  closed  by  sutures,  a  drainage  tube  inserted,  and 
the  part  covered  with  aseptic  lint,  and  retained  cold  by  a  thin 
ice-bag.  By  the  perseverance  of  the  treatment  here  briefly  indi- 
cated, an  occasional  patient  may  be  cured ;  the  majority,  however, 
will  })robably  fall  by  the  Avayside. 

Meningocele  and  Enccphaloccle. — By  meningocele  is  implied  a 
l)rotrusion,  hernia-like,  of  the  encephalic  membi'anes  through  an 
opening  in  the  wall  of  the  cranium;  and  the  content  of  such 
tumor  is  cerebro-spinal  fluid;  but  if  the  content  be  cerebral  or 
cerebellar,  then  the  tumor  is  named  encephalocele. 

Some  surgical  authorities,  for  instance,  St.  Germain,  deny  the 
existence  of  unconi])licated  meningocele;  on  tlie  contrary,  others, 
as  Spring,  as  determinedly  contend  for  its  existence. 

Encephalocele  may  appear  congenitally;  more  rarely,  it  is 
acquired;  a  few  examples  of  the  latter  have  been  seen,  in  which 
some  defect  of  the  cranial  wall,  due  usually  to  a  wound,  permitted 
the  esca})e  of  the  adjacent  meninges,  along  with  a  [)ortiou  of 
brain.  Such  hernial  protrusion  has  appeared  where  a  portion  of 
the  containing  wall  lias  been  removed;  the  membranes  with  fluid 
and  a  portion  of  brain  have  protruded,  and  afterwards  the  pro- 
truded brain  receded  and  the  patient  recovered. 

More  often  the  case  is  congenital,  and  from  its  containing  a 
portion  of  brain  along  with  the  meninges  which  cover  this,  it  is 
])roperly  named  meningo-encephalocele.  The  site  of  such  tumor 
may  be  frontal,  orbital,  occipital  and  basial. 

The  frontal  tumor  is  rarely  seated  wholly  in  the  os  frontis; 
more  often  it  appears  between  the  frontal  and  nasal  bones. 

The  orbital  variety  presents  itself  behind  the  eyeball,  near 
the  lachrymal  bone,  through  the  sphenoidal  fissure,  or  at  the 
spheno-maxillary  fissure. 

When  occipital  in  site,  it  may  contain  the  posterior  cerebral 
lobes,  or  the  cerebellar  lobes;  or  the  tumor  can  contain  both 
cerebral  and  cerebellar  lobes. 


MEXIXGOCELE    AXD    EXCEPHALOCELE.  271- 

AVhen  basial  in  location,  the  tumor  may  traverse  the  ethmoid 
bone,  the  body  of  the  sphenoid,  or  it  may  traverse  the  temporal 
wings  of  the  sphenoid  bone. 

The  meningo-encephalocele  is  composed  of  the  following  con- 
stituents: There  is  a  cutaneous  wall,  in  which  the  skin  is  thin  and 
the  hair  partly  or  wholly  disappears.  This  may  inflame  and 
open.  Beneath  this  lie  the  aponeurotic  structures  in  attenuated 
form,  thicker  in  the  occipital  variety  than  in  others.  The  next 
structure  is  the  dura  mater,  which  may  present  an  irregular  sur- 
face, stretched  and  uneven,  from  elevations  and  depressions. 
This  membrane  may  contain  a  section  of 'a  sinus.  The  arach- 
noid membrane  that  is  protruded,  continues  its  serous  secretion, 
wdnch  may  be  so  large  in  quantity  as  to  form  a  cyst-like  structure. 
The  prolapsed  portion  of  brain  mav  be  altered  in  character;  and 
if  it  be  a  part  containing  a  ventricle,  the  latter  may  be  much  dis- 
tended. 

Spring  and  others  think  the  primary  cause  is  encephalic 
dropsy;  and  the  part  is  protruded  through  some  abnormal  or 
accidental  opening  in  the  wall.  Others  refer  encephalocele  to 
hypertrophy  pf  the  brain.  The  tumor  is  sometimes  transparent, 
and  its  content  can  be  caused  to  fluctuate.  AVhen  the  protruded 
part  contains  a  ventricle,  the  latter  may  be  swollen  with  fluid; 
and  a  layer  of  fluid  exist  between  the  cerebral  structures  and  the 
meningeal  wall. 

This  tumor  has  commonly  a  disastrous  course,  and  the  life  of 
the  subject  usually  ends  in  a  few  j^ears,  and  this  depends  on  the 
fact  that  the  tumor  continuing. to  grow,  morbid  changes  in  the 
nerve  centres  are  induced,  which  soon  destroy  life;  such  patients 
have  reached  the  age  of  from  seventeen  to  fifty-five  years;  yet 
thej^  usually  die  much  earlier. 

Encephalocele  has  been  mistaken  for  a  benign  tumor,  and  an 
operation  on  such  encephalic  growth  done  inadvertently,  has 
caused  death.  A  distinguishing  characteristic  is  that  such  tumor 
may  be  reduced  in  volume  by  compression,  yet  the  pressure 
causes  coma,  nausea,  convulsions,  etc.  It  need  scarcely  be 
remembered  that  diagnostic  verification  by  such  pressure  must 
be  done  with  much  care. 

The  prognosis  is,  in  all  cases,  inauspicious;  and  more  so  in 
proportion  as  the  tumor  is  larger  in  volume;  when  small  as  a 
walnut,  possibly  a  cure  might  be  obtained ;  but  when  of  enormous 
size,  in  which  the  volume  of  the  tumor  almost  equals  the  remain- 
der of  the  head,  an  early  fatal  ending  is  the  only  possible  event. 


272  KXCErHALITIS,    OR    INFLAMMATION    OF    THE    DRAIN. 

The  latter  cases,  which  fall  Avithiii  the  domain  of  Teratology, 
shouhl  not  be  interfered  with,  but  left  to  the  care  of  nature,  whose 
liand  having  illy  molded  them,  soon  finds  a  way  to  remove  them. 

Treatment. — As  stated,  it  is  only  when  the  tumor  is  of  moder- 
ate dimensions  that  it  becomes  a  proper  subject  for  surgical 
treatment;  and  this  may  consist  of  one  of  the  following  plans: 
Simple  aspiration,  aspiration  combined  with  compression,  com- 
pression alone,  ligation,  or  excision.  Aspiration  is  the  simplest 
and  safest  of  the  several  plans  here  enumerated;  and  if  it  be 
often  repeated,  possibly  a  cure  might  be  accomplished  by  it  if  the 
tumor  be  a  small  one.*  The  plan  is  rendered  more  effective  if 
along  with  the  aspiration  there  be  combined  comjDression;  for  this 
purpose  a  compress  may  be  maintained  over  the  part  by  means  of 
an  elastic  band  or  bandage,  or  a  truss-like  appliance  may  be  em- 
ployed, or  the  treatment  might  consist  of  simple  compression  of 
the  tumor  maintained  by  one  of  the  plans  just  mentioned.  The 
tumor  has  been  removed  by  ligation,  by  wdiich  it  is  tied  tightlv 
around  its  base,  and  the  part  beyond  being  strangulated,  dies  and 
is  detached.  And,  lastly,  the  removal  has  been  done  by  excision 
of  the  protruded  part. 

Therej^ort  of  the  results  obtained  by  these  several  methods  of 
treatment  is  unsatisfactory ;  a  majority  of  the  cases  died.  In  view 
of  this,  the  writer  would  hesitate  to  choose  any  of  these  plans,  and 
were  he  called  to  treat  a  case,  his  course  would  be  as  follows: 
After  making  an  incision  by  which  the  protruded  parts  could  be 
inspected,  let  the  prolapsed  bruin  be  restored  to  place  and  the 
wound  be  so  closed  as  to  retain  the  brain  in  its  normal  site.  To  aid 
ill  this  work,  a  compress  should  afterwards  be  retained  over  the 
part;  such  pressure  should  be  maintained  both  during  the  time 
of  healing,  as  well  as  some  time  afterwards. 

Hydrocephalus. — In  early  embryonic  age  the  cephalic  terminal 
protuberance  is  a  simple  capsule  of  water;  the  watery  content  is 
gradually  displaced  and  replaced  by  parts  constituting  the 
normal  brain;  and  remnants  of  these  primordial  water-cavity 
are  the  ventricles  of  the  brain.  From  disturbed  equilibrium 
of  the  forces  contained  in  development,  the  M-atery  content 
may  acquire  the  ascendent,  and  the  morbid  condition  called 
hydrocephalus,  or  better  named  hydrencephalus,  results.  The 
causal  agency  which  disturbs  the  balance  of  normal  develop- 
ment is  tliought  to  be  an  inflammation.  As  it  is  sometimes 
coincident  with  tubercular  heredity,  the  causation  is  referred  to 
tubercular  affection  of  the  cephalic  membranes.     As  the  fluid  is 


HYDROCEPHALUS.  273 

formed  v\-ichin  the  residual  cavities  or  ventricles  of  the  brain,  it 
may  also  be  designated  ventricular  dropsy.  The  disease  usually 
is  congenital,  dating  from  an  early  period  of  intra-uterine  life; 
yet  it  may  commence  and  develop  after  the  birth  of  the  child. 
Hydrocephalus  developing  in  utero  may  attain  a  great  size,  so. 
that  the  child  cannot  be  born  without  lessening  the  volume  of 
the  head;  in  such  cases,  if  the  head  does  not  spontaneously  burst 
during  labor,  the  accoucheur  is  often  compelled  to  tap  the  head 
and  thus  reduce  it  to  a  smaller  volume. 

Writers  on  this  subject  have  mentioned  numerous  causes  which 
may  predispose  to  the  disease;  among  these  are  the  following: 
Great  age  of  the  child's  parents,  their  abuse  of  alcoholic  drinks, 
excessive  sexual  indulgence,  compression  of  the  abdomen  during 
gestation,  and  compression  of  the  child's  head  during  delivery; 
these  things  mentioned  have  probably  but  little  influence  in 
originating  hydrocephalus;  more  probable  causes  are  disturbance 
of  the  circulation  in  the  foetal  head,  for  example,  some  agenc}- 
which  prevents  the  read}''  escape  of  the  venous  blood,  and,  as  a 
consequence,  the  serous  formation  predominates,  and  arrests  the 
normal  evolution  of  the  brain.  Where  cretinism  is  endemic, 
hydrocephalus  appears  in  the  offspring  as  the  alternating  disease. 
In  a  cretin  family  several  successive  children  have  had  the  dis- 
ease. Transmitted  syphilis  has  probably  been  a  frequent  causal 
factor,  the  gummy  growth  awakening  an  inflammation  in  the 
membranes;  or  such  growth  may  impede  the  return  of  blood 
along  the  venous  routes. 

The  Cjuantity  of  the  hydrocephalic  fluid  A'aries  according  to 
whether  it  is  formed  before  or  after  the  ossification  of  the  cranial 
bones;  before  the  completion  of  ossification  the  quantity  may 
become  very  great,  amounting  sometimes  to  over  twenty  pounds 
of  fluid;  but  the  quantity  is  small,  if  it  be  formed  after  the  bones 
are  ossified.  Examples  of  enormous  hydrocephalic  enlargement 
are  to  be  found  in  pathological  museums;  in  the  collection  of 
crania  made  by  Eetzius,  at  Stockholm,  the  writer  saw  a  specimen 
of  marvelous  dimensions,  greatly  excelling  anything  of  the  kind 
seen  elsewhere.  The  fluid  content  of  such  head  is  remarkable  for 
the  small  amount  of  solid  content;  this  content,  albuminoid  in 
character,  amounts  only  to  one  or  two  pai;ts  in  a  thousand. 

The  ventricular  cavities  of  the  brain  in  the  hydrocephalic 
subject  are  found  enlarged;  the  dividing  walls  between  these 
cavities  are  attenuated,  and  sometimes  torn  so  that  they  become 
one    common   space;  thus   the    lateral   ventricles   may   present 


'27-i  KNTKI'lIAI-ITIS,    OR     I N  FL.V  M>r  ATK  )N    Ol'    'I'lII')    liRAIX. 

one  sinylo  cuvily.  The  covering  of  the  lateral  ventricles  may 
atrophy  until,  linally,  they  assume  the  form  of  a  cystic  cavity: 
the  upper  thin  wall  of  this  being  ru2)turc(l,  the  flattened  rem- 
nants of  the  liemispheres  entirely  differ  from  normal  form,  and, 
on  their  lovolod  upper  surface,  one  finds  no  trace  of  the  third 
ventricle;  the  striated  bodies  are  also  compressed  into  flattened 
shape.     The  deformed  cerebral  matter  is  liistologically  changed. 

Sometimes  the  development  is  limited  toone-half  of  the  head; 
as  a  rule,  however,  the  entire  head  is  involved,  and  then  the 
enlargement  is  principally  in  the  frontal  and  occipital  regions. 
The  forehead,  in  height  and  breadth,  is  such  as  would  have 
delighted  the  eye  of  a  Gall  or  Spurzheim,  whose  ignorance  of 
anatomy  w^ould  have  j:)ermitted  tliem  to  mistake  water  for  brain. 
The  exces.sive  growth  of  the  frontal  bone  encroaches  on  tlie  orbit 
so  that  the  supra-orbital  arches  are  pre.ssed  downwards,  the  pal- 
pebral slits  are  narrowed  and  the  eyelids  are  rendered  ocdematous. 
The  temporal  fossae  are  effaced.  The  face  is  strikingly  small  when 
compared  with  the  overlying  head;  and  though  it  is  natural  in 
form  and  outline,  the  countenance  of  the  child  is  remarkable  for 
the  utter  effacement  from  it  of  all  the  lines  of  ordinary  intelligence; 
the  usual  mental  light  belonging  there  has  been  extinguished,  so 
that  though  the  pathologist's  eye  may  be  delighted  in  the  morbid 
and  atypical  which  are  present,  yet  the  parent  scarcely  finds  inter- 
est in  the  picture  of  his  demented  ofFsj)i'ing.  The  bones  of  the 
skull,  especially  those  of  the  cranial  vault,  become  thin  until 
they  are  as  flexible  as  parchment  and  are  separated  by  large 
interspaces;  ])ut  if  the  subject  survives  for  some  years,  ossific 
centres  appear  in  these  spaces,  and  develo])ing  as  "Wormian  ossi- 
cles, they  finally  complete  the  osseous  case.  The  auditory  meat- 
uses are  shallow  from  the  crowding  outwards  of  the  middle  ear. 

Hydrocephalus  is  often  associated  with  other  deformities, 
such  as  spina  bifida  and  harelip,  each  referable  to  a  common 
cause,  viz.,  arrested  and  ill-directed  development. 

The  child  may  be  born  with  the  head  apparentl}^  normal,  and 
soon  after  birth,  the  head  enlarging,  es})ecially  in  the  frontal 
region,  gives  signs  of  hydrocephalic  change.  And,  later,  the 
child  shows  dullness  of  intellect;  the  nutritive  functions  are  illy 
accomplished;  the  gust;,itive  sense  is  impaired  or  lost,  since  the 
child  swallows  with  equal  indifference  ill-tasting  matters  or 
proper  food.  The  arms  and  legs  are  retarded  in  their  growth  and 
are  moved  sluggishly  or  awkwardly,  or  they  may  l)e  the  subjects 
of  spasm  or  contracture.     Should  the  patient  learn  to  walk,  the 


TREATMENT    OF    HYDROCEPHALUS.  275 

gait  will  be  hesitating  and  uncertain.  Sometimes  there  are 
epileptiform  or  jerking  movements  of  the  limbs.  The  eyes  do 
not  act  in  unison,  but  often  move  divergently.  Vision  and  the 
other  special  senses  are  impaired, "^  as  might  be  inferred  from 
the  morbid  changes  in  the  brain. 

The  disease  is  ordinarily  chronic  in  its  course,  which  may  be 
varied  by  sudden  exacerbations;  from  paresis  of  the  limbs  the 
subject  may  be  forced  to  lie  in  bed;  and  epileptiform  attacks  may 
supervene.  Or  should  the  dropsical  fluid  cease  to  form,  the  sub- 
ject mav  so  far  improve  in  general  condition  that  he  may  live 
for  many  years,  though  he  remains  the  subject  of  arrested  or 
obtunded  intellect.  In  the  worst  cases,  the  fluid  continues  to 
augment  until  it  bursts  the  wall,  and  then  it  may  pa.ss  into  the 
tissues;  or  it  may  rupture  the  integument  and  escape  externally. 
It  has  escaped  through  the  nose.  Where  the  fluid  has  thus 
found  exit,  recovery  from  the  disease  has  been  reported.  The 
most  unfavorable  cases  seem  to  have  been  those  in  which  the 
cranium  did  not  continue  to  enlarge,  yet  the  fluid  continuing  to 
augment  caused  atrophy  of  the  brain. 

Treatment. — The  disease  has  been  combated  by  internal  medi- 
cation; as  remedies  used  have  been  calomel,  iodide  of  potassium, 
nitrate  of  potash,-  cantharides,  acetate  of  potash,  digitalis,  and 
turpentine;  also  by  cathartics  which  act  as  derivatives  on  the 
bowels.  Mercurial  ointment  has  been  apjDlied  to  the  shaven  scalp. 
All  impediments  to  the  free  return  of  blood  from  the  cranial 
cavity  should  be  removed.  An  attempt  has  been  made  to  pro- 
mote absorption  of  the  fluid  by  compression  of  the  skull;  thus 
strips  of  adhesive  plaster  may  be  so  used  as  to  form  a  cap  which 
will  maintain  con.stant  pressure  on  the  head.  Roux  in  1859 
announced  the  cure  of  a  case  by  the  aid  of  compression  con- 
tinued by  means  of  adhesive  plaster;  this  was  applied  at  first 
tightly,  and  later,  loosely.  All  the  methods  of  treatment  enumer- 
ated have  failed  to  cure  the  disease,  though  they  may  have 
retarded  its  progress.  If  the  writer  were  to  select  a  plan  of 
treatment  from  those  mentioned,  the  most  rational  would  seem 
to  be  that  by  compression;  and  for  this  he  would  use,  instead  of 
adhesive  strips,  a  rubber  bandage,  so  applied  as  to  maintain 
slight  and  uniform  pressure  on  the  head.  Such  compression 
should  be  commenced  in  the  early  stage  and  continued  for  a  long 
period.  Such  peripheral  pressure  would  counteract  secretion  and 
promote  absorption.  The  general  health  of  the  child  should  be 
diligently  maintained. 


27G  EN'CErir.VI.rTIS,    ok    I^•FLA^[^rATIO^'    OF    THE    lUlAIX. 

As  mild  operaiive  measure,  mat  of  capillary  drainage  might 
be  resorted  to.  For  this  procedure,  lirst  cleanse  the  scalp  with 
an  alcoholic  or  sublimated  solution:  and  then,  having  made  a 
small  incision  at  a  point  where  the  fluid  could  readily  be  reached, 
and  wliere  vessels  would  not  be  endangered,  introduce  through 
this  incision  a  tube  of  fine  calibre,  and  cover  this  with  borated 
or  sublimated  absorbent  hnt;  and  thus  an  outlet  for  the  slow 
escape  of  the  fluid  is  furnished,  and  provision  is  made  against  in- 
flammation of  the  structures  within  the  cranium.  By  this  means, 
tlie  slowly  escaping  fluid  becomes  an  ally  of  absorption;  the 
minute  vessels  which  are  the  agents  of  absorption  are  thus 
relieved  of  pressure,  and  their  functional  activity  is  promoted. 
As  an  ally  to  this  capillary  withdrawal,  compression  with  the 
rubber  bandage  may  be  made.  This  treatment,  to  be  successful, 
should  be  continued  for  some  weeks;  and  then,  if  the  disease  is 
not  controlled,  the  procedure  may  be  repeated  at  another  point. 

The  treatment,  however,  which  is  oftenest  pursued  is  that  of 
tapping;  this  method,  though  far  from  being  always  successful, 
has  so  often  been  followed  by  success  as  to  entitle  it  to  commen- 
dation. According  to  West,  who  has  collected  fifty-five  cases 
treated  by  tapping,  forty  died  and  fifteen  were  cured;  and  tliis 
was  in  the  days  of  infectant  surgery. 

Tapping,  which  is  best  done  by  the  method  of  aspiration, 
should  not  be  resorted  to  in  cases  in  which  there  is  but  a  small 
amount  of  fluid;  nor  in  those  in  whicli  the  amount  of  fluid  is 
stationary,  or  is  becoming  less  in  quantity.  Nor  should  it  be 
done  in  cases  in  which  the  head  is  enormously  enlarged,  and 
where  there  are  grave  defects  elsewhere  in  the  body.  It  would 
be  improper  where  the  subject  has  become  idiotic  and  will  con- 
tinue so.  The  cases  in  which  it  is  indicated  and  proper  are 
those  subjects  of  hydrocephalus  who  are  well  nourished  and 
otherwise  in  good  health,  and  in  whom  conservative  methods,  as 
compression  and  capillary  tapping,  have  failed  to  cure.  The  pro- 
cedure whicli  has  been  followed  b}^  the  best  results  is  that  in 
which  the  fluid  has  been  drawn  off  at  intervals,  in  moderate 
amount,  and  after  each  tapping  the  head  has  been  compressed. 

The  operation  i§  most  safely  done  by  aspirating;  yet  a  small 
trocar  will  answer  for  the  purpose,  if  care  be  taken  not  to  allow 
air  to  enter.  The  proper  site  is  where  fluctuation  is  evident,  and 
the  wall  to  be  penetrated  is  thin.  Such  sites  are  at  the  lateral 
angles  of  the  anterior  or  posterior  fontanelle,  wliere  neither 
venous  sinus  nor  meningeal  artery  will  be  imperiled.     A  small 


TREATMENT    OF    HYDROCEPHALUS.  277 

instrument  should  be  used,  and  having  displaced  the  skin,  the 
trocar  is  to  be  forced  towards  the  middle  of  the  lateral  ventricle, 
from  a  quarter  to  a  half  inch  in  depth.  The  fluid  should  not  be 
removed  in  such  amounts  as  to  permit  the  walls  to  fall  together; 
only  enough  should  be  withdrawn  to  remove  tension  and  swell- 
ing. If  the  content  be  entirely  withdrawn,  then  the  unsupported 
walls  sink  in  a  distorted  manner,  ilfter  the  withdrawal  of  the 
fluid,  the  wound  should  be  closed  with  adhesive  plaster,  and  the 
walls  compressed  by  a  rubber  bandage,  or  adhesive  strips.  In 
cases  which  have  been  cured  the  quantity  of  water,  which  has 
been  withdrawn,  has  been  from  one  and  a  half  to  three  ounces; 
and  when  the  fluid  reformed,  it  was  withdrawn  again. 

As  before  stated,  this  plan  of  treatment  has  been  so  rarely 
successful  that  some  surgeons  have  abandoned  its  use.  Among 
those  who  sanction  its  use  ma}^  be  cited  Bruns  and  Malgaigne, 
who  have  formulated  the  conditions  in  which  it  should  be  resorted 
to.  According  to  Bruns  it  should  only  be  done  in  cases  in  which 
the  fontanelles  and  sutures  are  widely  open,  the  cranial  bones 
are  freely  movable,  and  the  child,  behig  well  nourished  and  not 
paralyzed,  possesses  a  physical  and  mental  development  corre- 
sponding to  its  age;  and,  finally,  that  the  hydrocephalus  is  con- 
tinually augmenting.  Malgaigne  would  only  operate  wdien  the 
child  is  less  than  three  or  four  months  of  age,  and  the  disease 
seems  stationary;  exceptionally,  however,  he  would  do  it  if  the 
child  were  over  four  months  old,  and  the  disease  was  manifestly 
progressing  and  threatened  to  destroy  the  child's  life. 

As  a  modification  of  the  mode  of  tapping  above  described, 
Langenbeck,  in  1850,  did  the  work  through  the  orbit.  He  thrust 
the  trocar  beneath  the  upper  lid,  and  thus  reached  and  entered 
the  anterior  horn  of  the  lateral  ventricle;  thus  the  venous  sinuses 
and  the  meningeal  artery  are  avoided,  wdrich  are  endangered 
when  tapping  is  done  through  the  coronal  suture  or  the  anterior 
fontanelle.  Through  the  wound  left  in  the  orbit  the  fluid  continues 
to  drain  away.  Langenbeck  would  evacuate  from  three  to  six 
ounces,  according  to  the  volume  of  fluid  j^resent. 

There  are  cases  in  wdiicli  the  enormous  accumulation  of  fluid 
has  so  separated  the  bones  of  the  skull  and  enlarged  the  cavity 
that,  though  the  fluid  were  removed  and  did  not  reform,  the  con- 
ditions of  the  head  would  not  permit  the  continuance  of  life. 
Some  years  ago  the  idea  suggested  itself  to  the  author,  and  has 
probably  done  so  to  others,  that  the  unoccupied  space  might  be 
lessened  by  removing  a  portion  of  the  cranial  wall.     The  toler- 


278  ENCEPHALITIS,    OK    INFLAMMATION    OF    THE    BRAIN. 

aiice  of  the  iionual  skull  of  the  removal  of  sections  of  the  wall, 
and  the  impunity  with  which  the  hydrocephalic  skull  can  be 
pierced  in  tapping,  justify  the  belief  that  portions  of  the  latter 
might  safely  be  exsectcd.  A  few  years  since  the  writer  proposed 
such  an  operation  to  the  parents  of  a  hydrocephalic  child;  and 
it  was  on  the  eve  of  being  done  when  the  mother  interrupted  the 
matter  by  her  decision  that  she  would  rather  have  her  child  con- 
tinue an  imbecile  than  incur  any  risk  of  losing  its  life.  Doubtless, 
however,  such  an  operation,  if  it  has  not  already  been  tried,  will 
erelong  be  done,  and,  the  writer  predicts,  with  successful  event. 

As  before  stated,  liydrocephalus  developing  in  ntero  may 
render  delivering  of  the  foetus  impossible,  unless  the  volume  of 
the  head  be  reduced;  in  such  cases,  when  the  condition  is  dis- 
covered, as  soon  as  the  uterine  mouth  is  sufficiently  dilated,  a 
trocar  is  to  be  plunged  into  the  lateral  portion  of  a  fontanelle, 
and  the  fluid  evacuated.  Ill  these  cases  the  child  seldom  sur- 
vives birth  more  than  a  few  hours;  exceptions,  however,  have 
occurred  in  which  the  child  survived  for  some  time. 

•  This  di.sease  has  been  treated  by  a  combination  of  tapping, 
injecting  tincture  of  iodine,  and  compression.  The  writer  has 
recently  treated  a  case  in  this  way;  the  infant's  head,  which  was 
enormously  distended,  was  relieved  of  a  large  portion  of  its 
contents,  when  there  was  injected  a  twelve  per  cent  aqueous 
solution  of  the  compound  tincture  of  iodine.  This  being  intro- 
duced, the  head  was  strapped  with  adhesive  strips  so  as  to  main- 
tain compression.  Despite  this  course  the  fluid  soon  returned  and 
filled  the  cavity.  The  treatment  was  repeated,  with  the  same 
result,  and  the  case,  uncured,  returned  to  its  home  in  the  country. 
The  curative  results  obtained  by  injection  of  iodine  into  other 
serous  cavities,  as  tJje  pleural  and  peritoneal,  encourage  further 
trial  of  this  means  in  the  treatment  of  hydrocephalu.s. 

MicroceplialiLS. — It  is  a  fact  of  common  observation  that  a  dimin- 
ution of  the  yolume  of  the  cerebrum,  such  as  is  witnessed  in  con- 
genital hydrocephalus,  is  accompanied  by  mental  imbecility;  as 
the  bodies  of  such  children  grow,  their  intellect  does  not  develop 
correspondingly.  The  microcephalic  head  at  birth  usually 
presents  closure  of  the  sutures;  the  regions  of  the  fontanelles 
are  also  found  completely  ossified;  the  pulsatile  fountain  no  longer 
exists,  for  its  site  is  occupied  by  solid  bone,  and,  in  some  cases, 
the  osseous  formation  has  proceeded  so  far  that  the  sites  of  the 
fontanelles  are  elevated  above  the  contiguous  wall  of  the  skull. 
It  is  clear  that  in  such  microcephalous  head  osteo-genesis  has 


MICROCEPHALUS.  279 

proceeded  more  rapidly  than  is  tlie  case  in  the  normal  skull.  The 
skull,  then,  at  birth  is  a  solid  bone  case,  and  it  and  the  contained 
brain  are  abnormally  small.  In  such  an  infant  it  is  easily 
observed  that  the  ordinary  signs  of  developing  intellect  are  absent; 
the  child  is  not  observant,  or  but  little  so,  of  what  is  occurrino- 
around  it.  Objects  brought  before  its  eyes  are  scarcely  looked 
at;  and  if  the  object  be  moved  away,  the  eyes  do  not  follow  it. 
Accurate  fixation  of  the  eyes  is  absent,  and  the  two  eyes  do  not 
cooperate  in  the  act;  in  fact,  there  is  a  condition  of  mental  torpor 
which  marks  the  subject  as  idiotic,  or  but  slightly  removed  from 
idiocy. 

In  another  class  of  cases,  in  which  there  has  occurred  intra- 
uterine closure  of  the  sutures  and  fontanelles,  there  is  not  present 
the  condition  of  torpor  or  inertia  just  described.  The  infant,  as  it 
grows,  is  often  abnormally  quick  in  its  motions;  it  is  attracted 
by  sounds,  and  fixes  its  eyes  accurately  and  quickly  on  objects: 
it  makes  purposive  and  well-coordinated  movements  with  its 
hands  and  feet,  smiles,  and  is  pleased  with  the  caresses  and 
attentions  of  its  nurse;  still,  the  child  presents  none  of  the  com- 
mon signs  of  infantile  mind;  it  is  in  a  stage  of  mental  imbecility, 
from  which  it  does  not  emerge  as  its  body  grows. 

To  relieve  such  unfortunates,  the  aid  of  surgery  has  been 
invoked,  and  the  procedure  which  is  resorted  to  is  to  reopen  the 
closed  skull,  and,  having  removed  sections  of  bone,  to  provide 
open  spaces  which  will  permit  the  encephalon  to  develop.  By 
the  operation,  it  is  sought  to  place  the  infant's  head  somewhat  in 
the  condition  of  a  normally  formed  infantile  head. 

The  first  work  in  this  new  section  of  cerebral  surgery  was  done 
by  the  author  in  May,  1888,  and  the  idea  did  not  originate  with 
him,  but  in  the  mind  of  a  mother  who  had  the  misfortune  to 
have  such  an  infant.  This  child  was  born  with  complete  closure 
of  the  cranial  bones,  and  in  a  few  months  after  birth  it  betrayed 
signs  of  mental  defect.  The  mother  referred  its  condition  to 
the  closure  of  the  skull,  and  she  was  so  sure  that  this  was  so, 
that  she  wrote  to  me  from  her  home  in  the  country,  and  asked 
me  if  there  was  any  means  of  relieving  this  by  an  operation. 
In  her  graphic  language  she  said:  '' My  child's  brain  is  locked 
up,  and  can  you  not  unlock  it?"  The  author  advised  her  to 
bring  the  child  to  him,  which  she  did.  The  infant,  then  fifteen 
months  old,  was  well  nourished  and  perfect  in  every  respect, 
except  that  it  was  markedly  microcephalic,  and  evinced  but  few 
signs  of  mentality.     The  fontanelles  and  sutures  were  firmly  ossi- 


280  ENCEPHALITIS,    OR    INFLAMMATION'    OF    THE    BRAIN. 

fieJ;  the  site  of  the  anterior  fontanelle  was  somewhat  convex. 
The  child  had  free  use  of  its  limbs,  and  could  make  purposive 
movements  with  them.  In  view  of  the  hopeless  state  of  the 
cliild,  it  was  decided  to  operate  on  it,  and,  in  the  mother's  lan- 
guage, make  an  effort  to  "unlock  its  brain,"  and  this  work  was 
done  as  follows:  An  incision  was  made  in  the  median  line  of 
the  liairy  scalp  from  the  summit  of  the  forehead  to  somewhat 
beyond  the  posterior  fontanelle;  the  skin  with  the  periosteum 
was  uplifted  and  dissected  laterally,  so  as  to  expose  an  oblong 
section  of  the  skull  over  an  inch  in  width  and  some  inches  in 
length.  At  the  posterior  end  of  this  space  two  openings  were 
made  with  a  small  trephine,  through  which  a  blunt  dissecting 
instrument  could  be  passed,  and  the  dura  mater  separated  from 
the  bone.  This  detachment  was  done  between  the  openings  and 
also  for  a  short  distance  in  front  of  each  orifice.  la  the  space 
provided  by  this  separation  one  blade  of  a  pair  of  blunt  scissors 
was  passed,  and  the  bridge  of  bone  divided  which  separated  the 
trephined  openings;  also  in  front  of  each  0[)ening  a  similar 
division  of  the  bone  was  made  anteriorly  for  nearly  an  inch  in 
distance.  There  remained,  then,  a  portion  of  bone  attached  in 
front,  lying  over  the  longitudinal  sinus.  With  the  blunt  dissector, 
it  was  then  found  an  easy  matter  to  separate  this  bridge  of  inter- 
mediate bone  from  the  underlying  sinus,  and,  when  detached,  it 
was  uplifted  and  cut  off. 

Proceeding  in  this  way,  by  lateral  division  and  detachment  of 
another  section  of  bone,  the  work  was  done  without  difficulty,  in 
which  an  oblong  section  of  bone,  an  inch  wide,  reaching  from 
the  posterior  to  the  anterior  fontanelle  inclusive,  was  excised. 
There  was  found  no  difficulty  in  detaching  the  bone  from  the 
longitudinal  sinus  by  the  use  of  the  blunt  dissector  cautiously 
mani}»ulated.  8ome  small  drops  of  blood  oozed  from  the  sinus 
through  the  opening  of  minute  vessels,  which  passed  from  the 
cranial  wuU  to  the  sinus.  Besides  the  longitudinal  section  of 
bone  removed,  tliere  was  exsected  a  portion  transversely,  corre- 
sponding to  the  site  of  the  coronal  suture.  This  transver.se  sec- 
tion on  each  side  extended  one  inch  beyond  the  border  of  the 
longitudinal  one,  and  was  a  half  inch  broad;  the  vacant  space 
left  after  the  bone  was  exsected  was  cruciform. 

The  work  of  exsection  being  completed,  the  Avound  was 
dusted  with  iodoform  and  closed  by  sutures,  and  the  whole  cov- 
ered by  aseptic  lint.  During  this  operation  the  anaesthetic  acted 
badly;  the  child  was  greatly  depressed,  cyanosed,  and  was  nearly 


MICROCEPHALUS.  281 

lost  from  this  cause;  it  was  only  by  persevering  efforts  that  the 
child  was  resuscitated,  and,  though  rescued,  it  never  fully  rallied 
from  the  anaesthetic. 

The  anaesthesia  was  induced  by  a  mixture  of  chloroform, 
ether  and  alcohol.  The  child  lived  nearly  forty-eight  hours 
after  the  operation,  and  death  resulted  rather  from  the  ill  action 
of  the  aneesthetic  than  from  the  operation.  This  operation  was 
the  first  work  done,  as  far  as  the  writer  knew,  in  craniectomy 
performed  for  relief  of  mental  imbecility  due  to  microcephalus 
and  premature  closure  of  the  sutures  and  fontanelles;  and  the 
originating  thought  which  led  to  the  work  was  awakened  in  a 
mother's  mind  by  her  love  for  her  unfortunate  offspring. 

Since  this  operation,  which  was  not  published  at  the  time, 
craniectomy  for  the  relief  of  mental  arrest  due  to 'microcephalus 
has  been  proposed  and  done  by  Lannelongue  over  twenty  times; 
it  has  also  been  done  by  Keen,  of  Philadelphia,  and  others. 
Though  time  enough  has  not  elapsed  to  show  to  what  extent  it 
may  be  beneficial,  yet  the  reports  on  the  subject  are  favorable, 
especially  those  of  Lannelongue.  Unfortunately,  every  new 
procedure  in  surgery  has  the  fault  of  awakening  undue  expecta- 
tions in  those  who  originate  it,  and  this  one  may  share  the  fate 
of  many  others  which  have  failed  to  accomplish  for  subsequent 
operators  what  has  been  announced  by  those  whose  vision  was 
obscured  by  the  bias  of  paternity.  It  is  scarcely  probable  that  a 
brain  which  has  been  primarily  molded  according  to  a  micro- 
cephalic type  can  afterwards  be  much  changed,  for  such  brain  is 
as  perfect  in  all  the  detail  of  parts  as  is  a  normal  brain.  These 
parts  are  lacking  in  volume;  there  is  not  present  the  field  of  suf- 
ficient amplitude  for  the  growth  of  the  precious  germs  of  intel- 
lect; the  latter  consequently  develop  as  dwarfs.  And  it  scarcely 
seems  probable,  though  the  containing  rampart  be  enlarged, 
that  this  can  have  a  material  influence  on  the  cerebral  content. 
A  larger  bowl  held  before  a  flowing  stream  will  not  enlarge  the 
stream;  so  it  may  be  predicted  that  craniectomy,  done  in  the  best 
manner  which  can  be  devised,  will  afford  but  temporary  or  lim- 
ited relief  for  the  unfortunate  subjects  of  mental  imbecility.  The 
plan,  which  was  sketched  by  the  predetermining  hand  of  organ- 
izing Nature,  must  necessarily  remain  as  primarily  traced;  the 
attempt,  however,  to  rectify  or  improve  such  imperfect  sketch  is 
permissible,  if  not  laudable. 

A  few  weeks  prior  to  writing  these  lines,  the  author  was  con- 
sulted in  reference  to  an  infant  whose  head  could  scarcelv  be  des- 
19 


282  KXCKIMIALITIS,    oli    IXFLANrM ATION    OF    THE    BRAIN. 

igiiated  microcephalous,  yet  the  sutures  and  fontanelles  were 
closed  at  birth  and  there  were  signs  of  mental  inbecility  or  vacu- 
ity, and,  as  in  the  former  case,  the  parents  asked  to  have  some- 
thing done  for  the  assistance  of  their  child.  They  liad  been  told 
that  some  oi)eration,  for  relief  in  such  cases,  had  been  done  abroad, 
and  thev  wished  an  attempt  made  in  the  case  of  their  child. 
The  child  was  normal  in  other  respects,  j'^et  it  had  ceased  to 
observe  what  was  passing  around  it,  and  remained,  for  the  most 
of  the  time,  in  a  condition  of  listless  torpor. 

The  operation  was  done  somewhat  differently  from  tiie  former 
case.  The  infant,  aged  five  months,  was  placed  under  the  influ- 
ence of  the  mixed  ancesthetic  previously  mentioned,  wliicli  acted 
well  in  every  respect.  An  antero  posterior  incision,  over  the  left 
parietal  bone, was  made  connecting  and  reaching  somewhat  beyond 
the  anterior  and  posterior  fontanelles;  this  cut  reached  to  the  bone, 
and  was  followed  by  bilateral  uplifting  of  the  scalp  and  pericra- 
nium for  over  an  inch  on  each  side  of  the  lateral  inci.sion.  Next^ 
a  small  opening  was  trephined  through  the  bone  near  the  poste- 
rior end  of  the  bared  surface,  and,  through  this,  one  blade  of  a 
pair  of  scissors  was  passed,  and  an  oblong  section  of  bone  was  cut 
out  from  behind,  forwards.  This  was  a  half  inch  wide  and  over 
two  inches  long.  The  work  of  dividing  the  bone  was  always  pre- 
ceded by  the  separation  of  the  dura  mater  from  the  bone;  in 
this  way  the  scissors  did  not  catch  or  injure  the  dura  mater. 
Tins  oblong  section  was  not  excised  in  one  piece,  but  in  fragments 
about  three-quarters  of  an  inch  long.  A  similar  oblong  section 
was  excised  from  the  right  side,  through  a  longitudinal  cut  in  the 
scalp.  These  sections  of  bone  were  removed  so  as  to  leave  an 
interjacent  bridge  of  bone  lying  over  the  longitudinal  sinus ;  this 
bridge  was  an  inch  and  a  quarter  in  breadth.  There  was  next 
excised  a  portion  from  this  interlying  bridge,  corresponding  to 
the  anterior  fontanelle;  the  exsection  resembling  an  H.  The 
removal  of  the  lateral  portions  of  boJie  was  accompanied  by  but 
little  hemorrhage,  since  tlie  endings  of  the  middle  meningeal 
arteries  were  so  small  that  almost  no  Ijlood  escaped  from  them. 

Besides  the  work  of  osseous  exsection  here  described,  the  blunt 
dissecter  was  passed  in  between  the  remaining  bone  and  the  dura 
mater,  and  the  latter  was  separated  to  the  extent  of  an  inch  and 
a  half  beneath  the  remaining  fragmentary  parietal  bones.  The 
wounds  made  were  cleansed  by  a  twenty-five  per  cent  solution  of 
alcohol,  which  had  been  warmed  to  the  temperature  of  the  l)0(ly; 
thus,  in  its  contact  with  the  dura  mater,  the  cleansing  fluid  did 


MICEOCEPHALUS.  283 

not  cool  the  part  and  render  ansemic  the  brain  underneath.  In 
the  operation  done  three  years  previously,  this  precaution  was 
neglected, and  this  cause  should,  perhaps,  be  added  to  the  ill-acting 
anaesthetic,  to  explain  the  syncopated  state  into  which  the  cliild 
lapsed  during  the  operation,  and  remained  so  afterwards.  The 
wounds  closed  by  silken  sutures,  in  the  second  case,  were  covered 
with  lint,  moist  with  the  alcoholic  lotion,  and  they  healed  most 
rapidly;  only  where  the  bone  was  removed  from  the  region  of 
the  anterior  fontanelle,  did  a  slight  degree  of  suppuration  occur; 
the  healing  was  complete  within  ten  days.  The  skin  was  slightly 
depressed  over  the  site  of  the  bone  which  had  been  removed,  and, 
at  the  position  of  the  anterior  fontanelle,  there  was  the  pulsatile 
movement  which  characterizes  the  infantile  fontanelle  in  the 
normal  head.  Little  or  no  movement  was  perceptible  in  the 
region  where  the  oblong  exsection  had  been  done. 

The  most  remarkable  thing  in  this  operation  was  tne  slight 
impression  which  it  made  on  the  child;  the  temperature  hardly 
ever  rose  above  the  normal  one;  food  was  taken  and  digested  as 
usual,  and  there  was  no  nausea  or  vomiting,  as  is  usually  seen  as 
the  accompaniment  of  injury  of  the  head. 

The  ameliorating  result  of  the  operation  was  more  than  was 
expected;  there  was  a  visible  improvement  of  the  infant's  mental 
condition;  the  condition  of  apathetic  inertia  and  vacuity  of  intel- 
lect, which  previously  stamped  the  child  as  destined  to  idiocy, 
were  changed  somewhat;  the  child,  during  the  period  of  healing, 
commenced  to  look  at  wliat  was  passing  around  it;  it  would  fol- 
low a  moving  object  with  its  eyes,  which  it  did  not  do  before  the 
operation,  but  whether  the  improvement  will  continue,  time  will 
prove.  The  results  already  obtained  fully  justify  further  effort 
in  this  newly-opened  section  of  operative  surgery,  and  here,  as  in 
other  departments  of  surgical  work,  discretion  should  beused  in  the 
selection  of  proper  subjects  for  the  work.  Subjects  of  microceph- 
alus  in  whom  other  incurable  facial  deformity  exists,  as  is  some- 
times seen,  should  be  discarded.  Also,  cases  of  teratological 
monsters,  in  whose  construction  nature  has  forgotten  lier  sublime 
dexterity  and,  in  her  embryonic  sketch,  has  abandoned  those 
archetypal  lines  with  whicli  we  are  so  familiar  in  the  ordinary 
infant,  should  be  eliminated  from  the  list  selected  for  crani- 
ectomy. 

In  many  cases,  it  is  easy  to  foresee  that  the  ojoeration  will  be 
sought  by  unfortunate  parents  wlio  would  prefer  to  lose  the  life 
of  their  imbecile  waif,  rather  than  preserve  it.     However  desirable 


284  ENCEPHALITIS,    Oil    INFLAMMATION    OF    TlIF    1!KAIN. 

death  may  bo  in  this  ease,  as  Avell  as  in  others  which  fall  within 
the  physician's  and  surgeon's  observation  (and  desirable  it  indeed 
is),  yet  our  profession  has  no  such  power;  the  right  to  take  life  is 
only  delegated  to  another  profession,  whose  code,  formulated  from 
precedent  and  old  usage,  grants  authority  to  take  the  life  of  him 
who  has  taken  life.  If  such  a  right  or  power  can  be  exercised 
towards  the  murderer,  why  not  towards  him  whose  life  has  become 
a  curse  to  its  possessor?  When  Mirabeau  was  suffering  inexpres- 
sible agony  from  a  mortal  disease,  and  he  begged  Cabanis,  the 
celebrated  physician,  to  give  him  an  euthanasic  nepenthe,  the 
friend  replied  that  sucli  an  act  was  not  permitted.  The  great 
statesman  rebuked  the  refusal  by  saying:  "If  my  dog  were  suffer- 
ing and  going  to  die,  you  would  not  iiesitate  to  do  something 
which  would  end  his  misery,  and  in  so  doing  you  would  say  that 
you  were  doing  a  favor,  a  blessing;  am  I  not  better  tlian  my  dog? 
can  you  not  do  as  much  for  me?"  Cabanis  had  all  the  endow- 
ments of  the  tender-hearted  physician,  as  was  manifested  in  his 
endeavors  to  prove  that  death  by  the  guillotine  was  a  painless 
one,  in  a  work  written  to  solace  those  who  had  friends  who  died 
by  that  instrument  in  the  Frencli  Revolution;  yet,  in  answer  to 
the  suffering  statesman,  he  said:  "The  world  lias  not  yet  reached 
that  stage  of  civilization." 


CHAPTER  VII. 


SURGERY    OF    THE    EXTERNAL    EAR. 

The  auditory  apparatus  is  claimed  by  the  specialist  in  the 
treatineiit  of  disease  or  disorder  seated  in  any  portion  of  the 
apparatus;  the  general  surgeon,  however,  has  not  wholly  aban- 
doned this  region.  His  services  are  often  invoked  in  affection  of 
the  external  ear,  in  which  are  embraced  the  pinna,  or  external 
ear,  and  the  auditory  canal;  his  work  commonly  lies  outside  of 
the  tympanic  membrane,  and  to  this  section  of  the  subject  the 
present  chapter  will  be  confined.  As  preliminary  knowledge, 
necessary  to  a  correct  understanding  of  the  subjects  to  be  treated, 
the  writer  premises  a  brief  survey  of  some  of  the  anatomical 
characteristics  of  the  structures  comprising  the  pinna  and  meatus. 

The  external  ear  is  movable,  and  at  the  same  time  it  is  so 
strongly  attached  to  the  head  that  one,  grasping  the  ears,  can  lift 
the  entire  bod3^ 

The  ear  presents  a  multitude  of  forms,  and  may  vary  in  size 
so  that  the  smallest,  as  well  as  the  largest,  becomes  an  element  of 
deformity  in  the  subjects  figure.  The  condition  of  the  middle 
ear  seems,  sometimes,  to  be  indicated  by  the  conditions  of  the 
pinna;  for  if  this  be  verj'  flat,  dry  parchment  like,  angular,  and  with 
a  dwarfed  lobule,  there  may  be  inferred  to  coexist  sclerous  otitis. 
Whether  the  imperfectly  formed  ear  corresponds  with  an  imper- 
fect brain,  and  whether  the  assertion  of  Joux  be  justified  by  facts, 
viz.,  "Show  me  your  ear  and  I  will  tell  you  who  you  are,  and 
what  you  are,"  we  wdll  leave  for  the  otoscopist  and  psychologist  to 
determine.  The  supporting  framework  of  the  pinna,  instead  of 
being  bone,  as  is  elsewhere  found,  is  of  cartilage,  and  this  is  lined 
by  skin  which  adheres  closely  to  the  cartilage,  except  on  the 
posterior  side,  and  to  this  close  adherence  is  due  the  peculiarity 
of  form  which  characterizes  the  abscess,  hsematoma  and  cyst 
sometimes  occurring  here;  but  on  the  posterior  side,  the  skin  is 
loosely  adherent,  and  this  condition  permits  the  swelling  which 
is  seen  in  erysipelas,  seated  here.     The  lobule,  from  its  pendent 

(285) 


28G  SURGERY  OF  THE  EXTERNAL  EAR. 

j)Osition,  retains  its  form  and  site  witliout  the  intervention  of  the 
cartilage  which  maintains  the  form  of  the  rest  of  the  outer  ear, 
and  this  absence  of  cartilage  enables  the  surgeon  to  solve  a  plastic 
problem,  in  case  of  defect  here,  more  readily  than  elsewhere  in 
the  ear;  defect  in  the  cartilage-bearing  portion  maybe  restored 
from  parts  adjacent,  j'et  from  the  absence  of  the  cartilaginous 
framework,  such  plastic  work  rarely  retains  its  proper  form,  and, 
to  counteract  this  in  some  degree,  much  ingenuity  is  needed. 

The  external  auditory  meatus,  more  properly  named  a  ca- 
nal, is  the  continuation  of  the  external  ear  to  the  tympanic 
membrane.  This  passage  is  very  short  in  the  new-born  child; 
in  the  adult  it  varies  in  length,  and  among  those  who  have 
stated  itslenorth  there  is  but  slight  accord.  Buchanan  savs  it  is 
from  an  inch  and  a  quarter  to  an  inch  and  a  half  long;  accord- 
ing to  Comparetti  its  length  is  nine  lines,  while  Tillaux  makes 
its  length  vary  from  nine  and  a  half  lines  to  fourteen  and  a  half 
lines.  Its  breadth  varies  also  greatly,  and  the  outline  of  the 
transverse  section  varies  from  a  nearly  circular  figure  to  almost  an 
elliptical  form.  Its  long  axis  reaches  from  behind  forwards,  and 
from  without  inwards,  and  these  directions  correspond  with  those 
of  the  petrous  portion  of  the  temporal  bone.  The  auditory 
canal  is  not  straight,  but  is  curved,  so  that  a  longitudinal  section 
of  the  pa.ssage  is  convex  above  and  concave  beneath;  that  is,  the 
canal  at  its  middle  is  curved  upwards.  As  a  result  of  this  curv- 
ing, if  one  introduce  a  straight  speculum  which  fills  the  canal,  it 
will  strike  the  upper  wall  in  its  inmost  third  and  awaken  pain. 
Such  pain  may  be  avoided  b}^  pulling  the  pinna  directh'  upwards, 
as  thus  the  canal  is  somewhat  straightened. 

The  walls  of  the  canal  are  composed  of  cartilage  and  bone. 
The  outer  part  is  constituted  of  cartilage;  the  inner  portion  for 
more  than  one-half  its  extent  is  of  bone.  The  bony  wall  forms 
a  very  obtuse  angle  with  the  tympanic  membrane  above;  below, 
it  forms  a  correspondingly  acute  angle.  The  ceruminous  glands 
are  seated  chiefly  in  the  skin  which  lies  on  the  cartilage. 

The  superior,  posterior,  inferior  and  anterior  walls  of  the 
canal  may,  from  their  external  relations,  be  respectively  named 
the  cranial,  mastoid,  parotidean  and  temporo-maxillary  walls. 
The  cranial  wall  is  so  thin  here  that  a  wound  or  disease  in  the 
canal  may  easily  traverse  the  bone  and  affect  the  contiguous 
dura  mater.  Indirect  violence  having  ])rimary  impact  on  the 
chin  can  reach  the  brain  through  this  wall  and  produce  cerebral 
concussion.     Those  whose  brutal  profession  is  to  deal  blows  on 


SURGERY  OF  THE  EXTERNAL  EAR.  287 

the  bodies  of  their  fellows  are  well  aware  that  violence  applied 
here  is  most  certain  of  its  intended  effect,  for  a  blow  from  a  weak 
man  administered  to  a  powerful  man's  chin  will  fell  the  victim 
to  the  ship's  deck,  which,  as  the  writer  has  been  a  witness  of, 
was  once  no  infrequent  scene  of  such  violence. 

The  posterior  w^all  is  contiguous  to  the  mastoid  process,  and 
caries  of  this  latter  bone,  as  seen  in  the  scrofulous  subject,  may 
lead  to  suppuration  of  the  soft  parts  and  discharge  of  pus  into 
the  canal.  A  more  frequent  and  a  graver  trouble,  which  is  seen 
here,  is  where  a  deep-seated  inflammation  commences  in  the 
periosteum  lining  the  osseous  portion  of  the  canal,  and  extend- 
ing outwards  and  backwards,  appears  in  the  mastoidean  region; 
this  will  be  treated  of  more  fully  in  another  section. 

The  inferior  wall  lies  in  contact  with  the  parotid  gland,  so 
that  swelling  in  this  gland  may  partiall}'-  or  wholly  occlude  the 
external  meatus;  the  parotidean  growth  is  a  frequent  cause  of 
such  closure.  Thus,  as  the  author  has  seen,  unilateral  deafness 
may  arise  from  the  develojDment  of  a  malignant  growth  in  front 
of  the  ear,  though  the  deeper  portions  of  the  organ  remain 
unaffected.  By  an  extirpation  of  the  growth  in  such  a  case 
hearing  in  the  ear  was  restored.  The  close  contact  of  the  parotid 
gland  and  ear  explains  the  tinnitus  and  pain  in  the  ear  present 
in  parotitis. 

The  temporo-maxillary  or  anterior  wall  is  in  contact  with  the 
temporo-maxillary  articulations,  and  this  proximity  is  the  cause 
of  the  pain  which  is  caused  by  masticating  when  the  anterior 
wall' is  inflamed. 

After  birth  the  auditory  canal  becomes  deeper,  and  the  tym- 
panic wall  changes  its  position  as  the  cranium  is  developed. 
This  change  in  position  is  as  follows:  At  birth  the  membrane  is 
elevated  but  slightly  above  the  plane  of  the  horizon;  the  mem- 
brane makes  with  that  plane  an  angle  of  ten  degrees.  As  the 
child  grows,  the  membrane  rises  towards  the  vertical  plane,  and 
ends  normally,  in  making  with  the  horizon  an  angle  of  forty -five 
degrees.  In  the  cretin  and  non-developed  head,  the  tympanic 
membrane  occupies  the  position  of  that  of  the  infant;  hence, 
according  to  the  anthropologist,  this  angle  is  an  index  of  the 
grade  of  intellect;  so  that,  if  this  be  true,  wath  the  quadrant  one 
might  measure  the  height  of  the  sun  of  reason  and  the  latitude 
of  the  understanding.  This  matter  concerns  the  surgeon  less 
than  the  fact  that  this  disposition  of  the  membrana  tympani  ren- 
ders the  upper  wall  of  the  auditory  canal  shorter  than  the  lower 


288  SURGERY  OF  THE  EXTERNAL  EAR. 

one;  and  the  inclined  membrane  is  thus  made  to  form  a  recess 
on  tlie  lower  wall,  in  which  small  foreign  bodies  may  lodge. 
Drawing  the  pinna  upwards  tends  to  lessen  this  recess,  and  to 
bring  what  may  Le  lodged  there  into  view. 

Dcfccta  and  Affcci ions  of  the  External  Ear. — Congenital  defects 
are  met  with  in  the  pinna  and  auditory  canal.  The  pinna  may 
be  wholly  or  partially  wanting.  When  wanting,  if  one  palpates 
the  site,  as  tlie  author  has  verified,  there  may  often  befelt  traces  of 
cartilage  buried  beneath  the  surface;  and  in  one  case  portions  of 
the  cartilage  cropped  out  and  were  visible  above  the  surface.  In 
two  instances  of  such  defect  the  meatus  was  closed,  and  so  effec- 
tually that  it  was  difficult  to  precisely  locate  its  proper  site.  In 
these  two  cases  the  writer  attempted  by  a  plastic  operation  to 
remedy  the  condition.  The  buried  cartilage  was  uncovered,  and, 
along  with  a  portion  of  integument,  it  was  so  uplifted  as  to  present 
the  appearance  of  an  ear.  Unfortunately  for  satisfactory  form 
and  aspect  the  cartilage  found  was  very  imperfect.  The  opera- 
tive procedure  consisted  in  first  marking  off  a  portion  of  skin  in 
outline  similar  to  an  ear,  yet  longer;  next  was  incised  and 
dissected  up  the  skin  until  the  site  of  the  cartilage  was  approached; 
then  the  knife  was  carried  deeper,  so  as  to  include  and  pass 
beneath  the  cartilage  at  two  or  more  points.  In  this  way  the 
material  for  the  new  aural  formation  may  be  prepared,  wdien  the 
uplifted  integument  is  to  be  infolded  about  the  cartilage,  and 
fixed  in  place  by  fine  metallic  sutures.  Along  with  this  work  an 
attempt  must  be  made  to  open  the  closed  canal,  and  this  is  easily 
done  if  the  passage  be  merely  closed  by  an  external  operculum, 
for  the  meatus  is  restored  by  crucially  incising  the  covering,  and 
then,  having  seized  each  hanging  portion,  cut  it  off,  so  as  to  fully 
restore  the  outlet.  And,  to  render  and  preserve  the  orifice  per- 
manently patent,  tlie  hanging  flap  of  the  divided  operculum 
may  be  dissected  up  at  its  attached  base,  and  thus  a  small  cuta- 
neous covering  be  made  and  sutured  to  the  wounded  circumfer- 
ence. Thus,  in  such  congenital  closure,  the  opening  may  be 
restored,  but  if  the  occluding  material  reach  inwards  still  deeper, 
an  effort  should  be  made  to  restore  the  opening;  but  if  the 
canal  should  be  found  occluded,  or  rather  obliterated,  throughout 
its  entire  length,  then  the  operation  must  fail  in  its  purposes. 

A  duplicate  auditory  canal  has  been  seen  by  Velpeau ;  along- 
side of  the  normal  one  there  was  an  abnormal  canal  which  pene- 
trated to  the  mastoid  process.  In  such  a  case  the  surgeon's  inter- 
ference would  not  benecessarv. 


AFFECTIONS    OF    THE   EXTERNAL    EAR. 


289 


A  singular  anomaly  was  seen  by  Birkett,  in  wliicli  there  were 
two  pinnse  on  one  side;  the  surplus  one  was  removed  by  a  sim- 
ple operation. 

Congenital  cleft  or  fissure  in  the  external  ear  has  been  seen; 
Schwabach,  who  has  given  study  to  the  matter,  refers  the  origin 
of  such  fissure  to  the  embryonic  bronchial  cleft,  which,  not 
properly  closing,  leaves  a  fissure.  Such  fissure  has  been  observed 
by  Paget  and  Urbant-Schitsch.  In  several  cases  the  defect  was 
transmitted  from  parents. 

From  diminution,  as  well  as  excess  of  volume,  the  pinna 
may  be  deformed.  Besides  being  too  small,  the  ear  may  be  ill- 
formed;  such  dwarfed  auricle  might  possibly  receive  some  plastic 
aid, yet,  in  such  effort,  the  surgeon  should  not  try  to  do  too  much, 
lest  he  make  that  which  is  bad  still  worse. 

In  case  of  excess  of  volume,  in  which  the  parts  are  in  proper 
proportion,  the   surgeon  has  intervened   with  advantage.      In 


Figure  3.    Illustrating  Martino's  method  of  lessening  the  pinna;  tlie  section 
ac  being  removed,  the  closure  is  seen  in  the  figure  at  the  right. 

such  ear  enlarged  to  deformity,  the  work  may  be  done  as  was 
done  by  Martino,  who  removed  a  cuneiform  section  from  the 
middle  third  of  the  pinna  (as  shown  in  Figure  3).  Such  a  sec- 
tion should  traverse  the  concha,  ending  near  the  meatus,  and 
should  embrace  as  much  of  the  convex  border  of  the  ear  as  is 
requisite  to  reduce  the  part  to  better  shape.  The  opposite  borders 
of  the  remaining  gap  must  be  accurately  brought  together,  and 
retained  so  by  fine  metallic  sutures,  which  should  remain  in  place 
for  not  less  than  two  weeks.  The  part  should  be  immobilized  by 
aseptic  lint  placed  between  the  ear  and  the  head,  as  well  as  on 
the  ear;  the  whole  to  be  permanently  fixed  by  adhesive  plaster 
encircling  that  side  of  the  head.     In  this  way,  the  wounded  parts 


290  8rK(ii;i;v  of  tiih  kxtkuxal  ear. 

woulil  unite;  and  if  accurately  coaptated,  the  remaining  scar 
would  nitt  be  an  unsightly  one.  Wounded  cartilage  does  lieal, 
despite  the  contrary  opinion  which  was  taught  by  the  medical 
writers  of  antiquity. 

Wounds  of  the  External  Ear. — The  external  ear  may  be  the 
subject  of  a  piercing,  incising  or  contusing  wound. 

A  penetrating  or  piercing  wound  here  will  readily  close,  if 
placed  in  proper  conditions  of  cleanliness,  and  covered  by  an 
occlusive  dressing. 

An  incised  wound  may  form  a  flap,  or  the  detachment  of  a 
portion  of  the  ear  may  be  complete.  When  there  has  been  no 
loss  of  structure,  the  wound,  if  one  of  even  surface,  should  be 
closed  by  means  of  metallic  sutures,  immobilized  and  covered 
by  an  aseptic  dressing.  In  the  use  of  sutures,  these  should  be  so 
introduced  as  to  maintain  complete  coaptation  and  adjustment 
of  the  wounded  surface;  thus  done,  the  reunion  will  be  secured, 
and  deforming  surface  or  outline,  avoided.  The  sutures  must  be 
removed  so  as  not  to  disturb  the  united  parts;  and  this  should 
not  be  done  until  a  week  has  elapsed  since  the  sutures  were 
inserted;  and  even  a  longer  time  must  elapse  if  the  union  seems 
yet  incomplete.  Delay  in  the  removal  is  more  necessary  here 
than  elsewhere,  since  the  unsupported  position  of  the  ear,  differ- 
ing from  other  structures  which  have  subjacent  support,  renders 
a  wound  in  the  ear  more  apt  to  be  reopened  than  is  the  case 
elsewhere.  In  case  the  injury  be  a  compound  of  incision  and 
contusion,  then  the  contused  structure  must  be  removed  by  sharp- 
edged  scissors,  before  sutures  are  introduced.  And  this  trimming 
should  be  so  done  that  the  oppo.site  faces  can  be  congruently  fitted 
to  each  other.  If  this  precautionary  preparation  be  neglected, 
then  the  wounded  parts  may  unite  imperfectly,  with,  perhaps, 
one  or  more  perforating  gaps  through  the  ear. 

In  case  there  be  detachment  of  a  portion  of  the  pinna,  then  it 
has  been  repeatedly  demonstrated  that  the  separated  part  can  be 
made  to  reunite  again:  examples,  even  of  the  reunion  of  the 
entire  ear  after  its  detachment  have  been  seen.  A  noted  instance 
of  this  kind  is  that  of  Prynne,  a  member  of  the  English  Parlia- 
ment, who,  on  account  of  some  writings  then  adjudged  libelous, 
was  condemned  to  have  his  ears  cutoff;  though  this  was  over  two 
centuries  ago,  yet  surgical  art  in  this  field,  from  repeated  oppor- 
tunities, had  reached  such  proficiency  that  the  excised  ears  were 
.successfully  restored  to  their  places  again.  The  rebuke  of  muti- 
lation failed  of  its  effect.     After  three  years  his  pen  repeated  its 


OTPI/EMATOMA.  291 

offense,  and  Prynne  was  again  condemned  to  have  his  ears  cut 
off;  the  cruel  work  was  repeated  by  the  baihff ;  yet  surgery  was 
denied  the  privilege  of  another  trial  of  replacing  the  parts, 
since  this  time  the  ears  were  confiscated.  As  the  era  has  fortu- 
nately passed  in  which  the  conscience,  private  judgment,  and 
religious  opinions  of  men  are  controlled  by  the  lash,  pillory, 
stocks  and  mutilating  instruments,  surgery  has  less  opportunity 
of  testing  its  resources  in  tbis  field  of  restoration,  than  in  the 
much- vaunted  "good  old  times."  Accidental  injury,  however, 
does  sometimes  furnish  an  opportunity  for  work  in  this  line,  as 
shown  by  the  monograph  in  1870,  of  Berenger-Ferraud,  in  which 
there  is  a  collection  of  cases  of  restoration,  in  which  there  had 
been  partial  or  complete  detachment  of  a  portion  of  the  ear.  In 
one  case  told  by  Manni,  the  ear  had  been  cut  off  for  hours,  and 
carried  in  the  man's  pocket;  this  ear,  properly  replaced  by  sutures, 
reunited  without  any  necrosis  of  cartilage;  in  this  respect  diflPer- 
ing  from  a  detached  finger,  from  which  when  restored,  the  bone 
is  apt  to  die  and  be  thrown  out.  Berenger-Ferraud  hints  that 
there  may  be  some  benefit  for  a  short  time  elapsing,  between  the 
cutting  off  of  the  ear  and  its  restoration  ;  for  thus  done,  there  is 
time  for  the  bleeding  to  cease,  and  no  intervening  blood  prevents 
adhesion. 

To  restore  a  detached  portion  of  the  ear,  coaptate  accurately 
by  the  aid  of  metallic  sutures,  immobilize  the  part,  retain  the 
patient  in  recumbence,  apply  moderate  warmth  without  mois- 
ture and  let  the  dressing  remain  unchanged  for  three  or  four 
days. 

Erysipelas  not  unfrequently  appears  on  the  pinna;  and  it 
may  arise  here  primarily,  or  the  disease  may  appear  first  in  the 
scalp  or  face,  and  emigrate  then  to  the  ear.  It  may  run  an  acute 
course,  or  it  may  be  chronic  in  duration;  and  in  the  latter  case, 
it  may  appear,  vanish,  and  then  reappear  on  the  same  site. 
This  chronic  form  can  end  in  shriveling  and  contraction  of  the 
pinna,  thus  causing  marked  deformity.  In  its  acute  form  the 
disease  usually  enters  the  meatus,  and  passing  inwards  it  causes 
tinnitus. 

Treatmeiit. — Mercurial  or  iodine  ointment,  or  one  containing 
quinine,  two  grains  to  the  ounce,  may  be  used  locally. 

Othsematoma. — Since  the  othematoma  is  sometimes,  if  not  al- 
ways, of  traumatic  origin,  it  is  proper  to  consider  the  subject  here. 
The  name  othsematoma  or  hgematoma  of  the  ear  was  applied  by 
Weiss,  of  Coblitz,  to  a  soft  fluctuating  tumor  which  suddenly 


202  SUROEKY  OF  TIIK  KXTKKXA  I,  KAM. 

appears  on  the  pinna.  It  has  also  been  named  auricular  ery- 
sipelas, blood-cyst  of  the  ear,  and  shriveled  ear.  It  occurs  most 
fre(|uently  in  tlie  insane.  This  tumor,  which  usually  appears  on 
the  outer  face  of  tlie  ear,  within  depressions  bounded  by  the 
helix  and  antihelix,  may  attain  such  dimensions  as  to  interfere 
with  liearinir;  and  in  the  bcirinnintr,  it  is  somewhat  iiainful,  and 
soon  inaiiifests  symptoms  of  inflammniion  in  Ijcing  hot,  red  and 
swollen. 

Tliere  have  been  assigned  two  modes  of  origin  of  this  tumor: 
in  one  it  is  claimed  that  it  originates  from  a  constitutional  or 
general  cause;  and  in  the  other,  it  is  contended  that  the  tumor 
is  the  result  of  local  injury.  Hasse,  who  has  seen  six  cases, 
espouses  the  latter  opinion;  he  thinks  that  it  is  caused  by  pull- 
ing the  ear,  or  by  frequent  blows  on  the  part.  From  such  vio- 
lence the  lining  of  the  cartilage  can  be  cracked,  or  so  injured 
that  the  blood  can  insinuate  itself  into  the  fissure  and  uplift  the 
lining  membrane.  Such  violence  might  be  done  by  the  patient 
himself.  Tlie  tumor  has  oftenest  been  seen  in  the  inmates  of 
asylums  for  the  insane;  and  hence  the  origin  of  an  otha3matonia 
has  been  discussed  in  courts  of  law,  at  whose  bar  the  managers  of 
such  institutions  have  been  arraigned  under  accusation  of  cruelty 
to  the  inmates  in  their  charge.  On  such  occasion  the  question  has 
been  mooted  whether  the  subject  may  not  have  caused  tlie  vio 
lence  himself  by  striking  his  head  against  some  object. 

That  the  tumor  may  be  caused  by  violence,  voluntarily  or 
otherwise  inflicted,  is  shown  by  the  fact  that  it  has  often  been 
seen  among  the  knights  of  the  arena  whose  ears  are  the  subject 
of  many  blows;  and  in  such  it  occurs  oftener  in  the  left  ear. 
This  tumor  was  not  unknown  to  the  ancients;  and  the  artist 
who  chiseled  the  ears  of  Hercules,  and  those  of  Castor  and  Pollux, 
has  delineated  those  famous  athletes  of  the  mythic  age  as  bearing 
ears  deformed  by  this  affection. 

Others,  again,  contend  against  a  traumatic  origin;  this  opin- 
ion is  espoused  by  Ludwig  Meyer  and  Virchow.  Meyer,  in  1865, 
in  an  essay  on  this  subject,  claims  that  othiematoma  arises  from  a 
chondroraatous  degeneration  of  the  aural  cartilage,  wliich  is  suc- 
ceeded by  the  vascular  development  in  the  part  so  changed.  He 
finds  three  kinds  of  alteration  in  the  cartilage,  the  hyaline  and 
fibrillar  degeneration,  and  the  formation  of  hollow  spaces  in  the 
cartilage.  Virchow,  likewise,  though  admitting  that  the  tumor 
may  have  a  traumatic  origin,  still  claims  that  it  can  arise  from 
changes  which  primarily  occurred  in  the  cartilage  itself,  and 


OTHEMATOMA.  293 

which  were  afterwards  followed  by  the  vascular  etfusion.  Perti- 
nent to  this  matter  is  an  interesting  observation  made  by  Brown- 
Sequard,  that  from  injuries  of  the  restiform  columns  of  the 
medulla  oblongata  in  the  guinea  pig,  there  soon  appeared  vascu- 
lar effusion  in  the  animal's  ears,  consequent,  he  thinks,  on  the 
iinpairment  of  nutrition  produced  by  the  injury  to  the  cord. 
The  author  of  this  work  suggests  that  it  is  possible  that  the  ani- 
mal, in  his  wounded  condition,  injured  himself. 

As  summary  then  of  the  causation  which  has  been  assigned 
to  ex2:)lain  the  origin  of  othsematoma  are  the  following  agencies: 
from  local  violence  of  the  part  frequently  repeated,  from  troubles 
of  general  nutrition;  and,  thirdly,  from  a  disturbance  of  the  local 
nutrition  of  the  ear. 

When  the  othsematoma  is  slight  and  multiple  in  site,  it  resem- 
bles somewhat  erysipelas,  differing,  however,  from  the  latter  in 
being  a  fluctuating  tumor,  and  nearly  always  seated  on  the 
external  face  of  the  ear.  It  may  slowly  grow  until  the  tumor 
occupies  the  entire  outer  face  of  the  pinna.  The  tumor  may 
also  penetrate  through  the  ear,  and  then  it  communicates  with, 
or  forms,  a  tumor  on  the  inner  face  of  the  pinna,  looking  towards 
the  scalp.     The  content,  though  clotted,  is  liquid  in  its  centre. 

The  othsematoma  presents  a  .varied  course;  sometimes  it 
vanishes  through  absorptive  dispersion  of  its  contents;  it  can 
inflame,  suppurate  and  open,  and  disappear  in  this  way;  or  the 
tumor  may  remain  an  indefinite  period,  and,  as  it  is  then  pain- 
less, it  is  chiefly  objectionable  from  the  deformity  which  it  causes. 

When  the  tumor  disapj)ears  through  spontaneous  absorption, 
or,  through  suppuration  and  evacuation  of  content,  it  entails 
some  change  in  the  form  of  the  pinna;  the  affected  part  shrivels, 
and  the  concha  is  deformed  through  contraction.  The  final 
deformity,  in  the  main,  is  one  of  shriveling;  and  this,  as  above 
stated,  has  not  been  forgotten  by  the  ancient  sculptor. 

Treatment. — In  the  early  stage,  inflammatory  action  should  be 
controlled,  and  absorption  promoted;  for  the  former,  lead  water, 
and  for  the  latter,  some  compound  of  iodine  may  be  topically 
used.  If  reduction  is  not  accomplished  by  these  measures,  then 
the  knife  may  be  used;  and  through  proper  incisions,  the  blood 
may  be  forced  out,  and  tincture  of  iodine,  or  iodoform,  introduced 
into  the  emptied  spaces.  As  the  blood  soon  refills  the  cavity, 
other  means  have  been  resorted  to  for  relief:  viz.,  there  may  be 
passed  a  seton  through  the  tumor,  which  is  allowed  to  remain 
there  perriaanently.     In  this  way  it  is  claimed  that  the  blood  finds 


2t>4  SURGERY    OK    Til  I!    KXTKJiNAI,    K.VR. 

escape  as  soon  as  it  forms,  and  the  cavity  gradually  closes. 
Wilde  treated  tiie  tumor  by  freely  incisino-  it,  emptying-  the  con- 
tents and  tilling  the  cavity  with  lint. 

The  sebaceous  cyst  occurs  on  the  ear,  oftener  on  the  outer 
surface.  Such  cyst  commonly  remains  of  diminutive  size,  though 
it  may  become  as  large  as  an  olive.  It  is  treated  by  incision  and 
removal  of  the  sebaceous  material  by  compression  or  curetting. 
The  spoon-shaped  end  of  the  grooved  director  is  a  convenient 
instrument  for  scooping  out  the  contents  in  most  cases.  Akin  to 
the  sebaceous  cyst  is  the  chalky  concretion  sometimes  found  here. 
Tlie  Engli.sh  writers  associate  this  with  a  gouty  diathesis.  Such 
material  may  l)e  removed  by  curetting. 

The  fiijroid  tumor  occurs  iii  the  pinna;  its  origin  may  be 
spontaneous,  or  it  may  arise  from  some  i)revious  injury.  The 
usual  site  is  the  lobule,  where  it  has  ari.sen  from  the  irritation 
excited  by  an  ear-ring.  Such  growth  can  attain  the  size  of  a 
small  cherry.  It  may  partake  of  the  nature  of  keloid  structure, 
and  then  it  is  the  site  of  an  itching  sensation.  Such  growth 
being  in  the  female  and  an  offense  to  her  eye  as  well  as  to  the 
eyes  of  others,  its  removal  is  urgently  solicited  b}''  the  patient. 
This  is  done  by  extirpation,  which  should  be  done  from  the 
inner  surface  of  the  lobule;. and  in  the  work  two  points  must 
be  observed :  one,  to  remove  the  tibromatous  structure  in  its 
entirety,  and  the  other  to  preserve  the  skin  and  remove  as  little 
as  possible  of  tlie  lobule;  and  these  rules  are  so  much  in  conflict 
with  each  other,  that  it  often  occurs  that  the  work  is  not  thor- 
oughh'  done,  and  sooner  or  later  there  is  a  recurrence  of  the 
growth,  as  has  happened  in  the  writer's  experience.  Should 
there  be  a  return,  another  removal  may  be  more  succe.ssful. 

Malignant  growths  appear  in  the  external  ear;  carcinoma, 
sarcoma  and  epithelioma  are  found  here.  Such  growth  may 
have  its  original  site  here,  or  it  may  invade  the  ear  as  an  immi- 
grant from  some  adjacent  part.  Epithelioma  is  oftener  seen 
than  the  other  forms  of  malignant  growth  just  mentioned.  It 
commences  usually  in  the  folded  border  of  the  pinna,  or  in  the 
prominent  portion  of  the  antihelix.  Owing  to  the  defective 
vascularity  of  the  peripheral  portions  of  the  pinna,  the  epithe- 
lial cell-growth  makes  but  slight  progress  before  ulceration 
ensues;  in  the  central  portions  of  the  concha,  the  growth  is 
greater,  and  proceeds  to  such  an  extent  that,  as  in  a  case  treated 
by  the  writer,  it  occluded  tlie  meatus,  and  deafened  the  patient 
on  that  side.     Carcinoma  is  more  rare  here;  in  fact,  thfe  structure 


OTH.EMATOMA.  295 

of  the  ear  is  but  little  favorable  to  the  development  of  this  type 
of  malignant  growtli;  still,  Sedillot  and  Duplay  have  observed 
cases  in  which  carcinoma  rapidly  destroyed  the  external  ear,  and 
attached  and  destroyed  the  subjacent  bone.  The  pinna  is  his- 
tologically ill  adapted  for  the  development  of  sarcoma,  and  the 
writer  has  seen  no  example  of  it  there. 

Malignant  neoplasm  seated  in  the  ear  should  be  attacked 
early  and  radically;  if  thus  treated,  the  case  can  be  cured,  as  has 
often  been  verified.  If,  however,  the  disease  has  made  such 
progress  that  it  has  appeared  in  the  adjacent  glands,  which  are 
connected  with  the  part  by  lymph-vessels,  then  recurrence  is 
almost  inevitable,  though  radical  means  be  used.  If  the  disease 
have  an  isolated  site,  this  should  be  so  circumscribed  as  to  surely 
include  the  affected  structure.  And  the  excision  should  be  done 
in  such  a  figure  that  the  wound  may  be  closed  and  leave  no 
conspicuous  gap  or  deformity  in  the  ear.  This  is  only  possible 
when  the  affected  part  is  limited  in  extent;  for  example,  when 
it  is  on  the  border  of  the  ear,  and  the  excision  can  be  done 
triangularly.  Bat  if  a  great  portion  of  the  ear  be  the  site,  then 
a  large  portion  of  the  pinna  must  be  excised;  if,  however,  a 
part  of  the  circumference  can  be  saved  and  attached  to  a  portion 
of  the  concha,  then  the  deformity  will  be  much  less  than  if  the 
entire  ear  be  excised.  In  a  case  operated  on  by  the  author,  in 
which  the  concha  and  entrance  of  the  canal  were  the  site  of 
epithelioma,  the  affected  parts  were  removed,  including  the  derm 
for  an  inch  around  the  meatus,  Avhich  was  likewise  implicated; 
there  was  left  remaining  the  upper  fourth  of  the  pinna,  along 
with  the  greater  portion  of  the  helix,  which  was  not  affected. 
The  part  which  remained  was  falciform,  being  broader  above 
and  gradually  tapering  to  a  sharp  point  behind  and  below;  the 
posterior  cutaneous  face  of  this  was  removed,  and  the  part  then 
fixed  by  metallic  sutures  to  the  dermal  edge  of  the  raw  surface 
which  remained  behind  tlie  meatus  after  the  excision  of  the 
affected  structure.  The  parotidean  sulcus  behind  and  below  the 
ear,  from  which  affected  structure  had  been  removed,  was  next 
covered  by  a  flap,  which  being  uplifted  from  over  the  upper  fifth 
of  the  sterno-cleido-mastoid  muscle  was  turned  across  the  large 
raw  gap.  By  the  work  thus  done  the  wounded  surface  was  in  a 
great  degree  covered,  and  the  portion  of  the  ear  which  remained, 
though  less  than  one-fourth  of  the  original  part,  was  so  utilized 
as  to  greatly  lessen  the  deformity.  In  healing,  the  meatus 
tended  to   close   cicatricially,    yet   this   was   prevented    by   the 


296  SURGERY  OF  THK  EXTKRXAL  EAR. 

insertion  of  a  rubber  tube.     There  was  no  recurrence  in  this  case. 

The  ]>inna  is  sometimes  the  site  of  a  lupoid  ulceration,  cog- 
nate in  feature  and  behavior  to  eiiiihelial  cancer,  and,  like  the 
latter,  it  occurs  oftenest  in  the  aged  subject.  It  would  seem  to 
ai)i)eai'  most  frerjuently  in  persons  in  whom  the  skin  is  dry  and 
the  site  of  freckles  and  other  pigmentary  marking.  In  the  senile 
period  of  general  lapsing  vitality,  this  structure,  which  is  rendered 
especially  non-resistant  by  its  pe  ipheral  situation,  becomes  the 
favorite  site  of  lupoid  development.  Histogenetic  weakness,  the 
result  of  such  condition,  favors  the  development  of  both  cell  or 
microphyte  to  w^hich  the  causal  agency  of  this  disease  is  attributed. 

For  the  extirpation  of  the  disease,  the  curette  and  escharotic 
are  oftener  resorted  to  than  the  knife.  Tlie  diseased  structure 
should  be  scraped  off  and  the  raw  breach  opened  should  be 
cauterized  with  potassafusa,  or  it  may  be  covered  with  a  paste  of 
sulphuric  acid  and  charcoal;  such  paste  is  allowed  to  dr}^  and 
remain  in  place  until  an  eschar  is  detached.  Or  a  paste  composed 
of  salicylic  acid  and  liquid  carbolic  acid  may  be  u.^ed  and  left  in 
place  until  the  resulting  eschar  drops  off.  Multiple  lupoid  points 
may  thus  be  treated  at  the  same  time. 

Adherent  Pinna. — Adherence  or  fusion  of  the  pinna  with  the 
adjacent  surface  of  the  head  appearing  congenitally  has  received 
sufficient  mention;  the  acquired  form  will  next  be  considered. 

From  burns,  eczematous  ulceration,  and  from  the  surgeon's 
instrument  the  adjacent  and  opposite  surfaces  of  the  ear  and  scalp 
may  be  denuded,  and  if  brought  in  continuous  contact,  the  sur- 
faces will  cohere.  Improper  head-dress  of  the  infant  has  caused 
it,  viz.,  one  by  which  the  ears  are  forced  against  the  head. 

This  condition  of  coherence  is  not  easy  to  completely  remove; 
though  detachment  be  done,  and  separation  maintained  by  some 
intervening  material,  still  there  will  occur  reunion  in  the  deep- 
est part  of  the  normal  sulcus.  To  oppose  such  union,  a  flap  of 
cutis  from  the  contiguous  sound  structure  may  be  lifted  up,  and 
twisted  in  and  sutured  to  the  floor  of  the  sulcus.  In  this  way 
the  deeper  part  of  the  normal  interval  Avill  be  maintained  open, 
and  when  this  is  done,  the  remainder  of  the  work  is  easily  accom- 
plished; for  if  parts  unite  beyond,  it  suffices  to  simply  separate 
them  and  maintain  the  surfaces  apart  by  some  intervening  lint. 
The  process  here  is  similar  to  that  done  for  the  separation  of 
webbed  fingers.  Skin  grafting  might  be  resorted  to  for  the  same 
purpose;  and  then  the  grafting  might  be  done  on  one  or  both 
surfaces. 


RENTS,    FISSURES    AND    OTHER    DEFECTS.  297 

Rents,  Fissures  and  other  Defect  in  which  there  is  loss  of  struc- 
ture.— The  simplest  case  of  this  kind,  and  not  unfrequently  seen, 
is  tliat  in  which  the  lobule  has  been  torn  by  the  ear-ring. 
Such  rent  occurs  oftener  from  accident,  by  which  the  ring  is  torn 
out,  or  from  continuous  ulceration  from  the  ring,  a  rent  arises. 
In  all  such  cases  restoration  to  normal  form,  or  at  least  fair  relief 
from  deformity,  is  obtained  by  paring  the  edges  evenly  and 
uniting  them  by  means  of  metallic  wire;  such  wire  must  be  verv 
fine. 

Sometimes  a  surgeon  is  consulted  in  reference  to  the  repair  of 
a  larger  or  smaller  loss  of  structure  of  the  ear.  Such  loss  may  be 
in  the  marginal  or  in  the  central  portion  of  the  pinna,  or  in  the 
lobules.  The  material  for  restoration  is  to  be  taken  from  the 
dermal  integument,  which  is  most  conveniently  situated,  and  this 
should  always  be  selected,  by  preference,  from  a  part  where  the 
subsequent  scar  will  not  be  visible;  and  ia  accordance  with  this, 
the  material  behind  the  ear  is  best  suited  for  replacement. 

The  difficulty  encountered  in  this  plastic  work  is  the  retention 
of  form.  Since  the  cutaneous  material  used  for  restoration  con- 
tains no  cartilage  when  it  is  transplanted  to  the  border  of  the  ear, 
it  soon  shrivels,  and  if  this  be  at  the  upper  border,  the  latter  soon 
shrinks  down  into  a  shapeless  figure.  To  avoid  this,  the  cartilage 
already  remaining  may  be  utilized;  to  do  this  a  strip-like  section 
may  be  cut  with  nutrient  connection  at  one  end,  while  the  free 
portion  is  lifted  and  placed  arch-like  on  the  border.  Into  the 
open  space  thus  left,  a  flap  of  skin,  uj^lifted  from  behind,  is 
inserted,  and  fixed  by  sutures.  In  this  work  the  epidermal  side 
of  the  flap  should  look  outwards.  The  vascularity  of  the  flap 
will  aid  in  maintaining  alive  tlie  newly  formed  cartilaginous 
border.  After  three  weeks  the  flap  can  be  cut  asunder  at  its  base, 
or  it  might  be  left  unsevered,  since  its  site  is  quite  concealed. 
In  operative  work  of  this  character,  the  author  has  verified  the 
advantage  of  thus  using  the  existing  cartilage  for  constructing  a 
border. 

If  such  expedient  in  the  technical  work  of  restoration  be  omit- 
ted, though  the  ear  be  well  repaired,  the  added  material  will  soon 
shrivel  and  the  operation  be  a  disappointment.  In  an  attempt 
by  the  writer  to  restore  a  large  breach  in  the  upper  half  of  tlie 
ear,  caused  by  the  bite  of  a  beast  in  form  similar  to  the  patient, 
the  primarily  well-restored  section  afterwards  shrank  to  unsatis- 
factory form;  and  thus  a  double  lesson  was  taught:  the  limita- 
tions of  plastic  repair,  and  the  inestimable  value  of  cartilage  in 
20 


208  SUKGEKY    OF    THE    KXTEKXAL    EAIl. 

the  arcliitecture  of  the  ear.  In  case  tlie  defect  be  central  tl»e 
repair  is  less  difficult,  since  if  the  peripheral  framework  of  the 
ear  remains,  the  newly-added  material  will  be  retained  in  its 
central  position.  And  in  such  a  case  the  restoration  is  done  by 
trimming  tlie  margin  of  the  opening  and  uplifting  a  flap  and 
adjusting  it  to  the  breach,  with  its  epidermal  surface  looking 
outwards. 

If  the  defect  in  the  ear  be  from  a  lost  lobulus,  the  work  of 
repair  can  be  satisfactorily  done  by  uplifting  a  flap  with  attach- 
ment below.  This  flap  should  be  so  broad  that  it  may  be  folded 
together  and  thus  present  a  skin-covered  surface  on  all  sides;  and 
the  whole  should  be  broader  and  thicker  than  the  part  which  it 
is  to  replace,  since  it  will  afterwards  diminish  in  size. 

Affections  of  the  Auditory  Canal. — Inflammatory  action  may 
arise  in  tlie  surface  of  the  canal,  originating  in  the  glandular 
structure  wliich  abounds  there;  such  inflammation  may  be 
limited  to  a  small  point,  viz.,  a  sebaceous  or  ceruminous  gland 
may  be  the  origin,  and  thence  a  diminutive  abscess  can  arise. 
Such  abscess,  tliough  i)ainful,  is  not  a  serious  trouble.  As  appli- 
cation, tliere  may  be  used  camphorated  oil,  or  almond  or  olive 
oil.  Also  warm  carbolized  water  should  occasionally  be  poured 
(not  injected)  into  the  passage,  so  as  to  remove  any  material 
which  may  be  emptied  into  the  passage.  The  suppuration  will 
be  hastened  and  the  pain  lessened  by  placing  over  the  ear  a 
poultice  of  hops  to  which  laudanum  has  been  added.  By  such 
management,  the  ordinary  aural  abscess  is  satisfactorily  treated. 
It  has,  however,  a  tendencj'' to  recur;  the  first  one  often  having 
several  successors. 

Besides  the  circumscribed  glandular  inflammation  just  men- 
tioned, there  is  another  form  of  a  much  graver  nature,  which  has 
been  studied  by  Tillaux.  According  to  him,  the  inflammation 
commences  in  the  periosteum  which  lines  the  deeper  portion  of 
the  canal,  and  travels  inwards,  and  follows  the  periosteum  that 
covers  the  mastoid  process  behind  the  ear.  Pus  forming,  o^^ens 
into  the  canal,  but  much  of  it  remains  confined  underneath  the 
thick  structures  which  cover  the  mastoid  process;  and  from  this 
fact  Tillaux  names  the  purulent  collection,  mastoid  abscess.  It  is 
probable  that  instead  of  originating  as  Tillaux  thinks,  in  the 
periosteum,  it  commences  in  the  deep  glandular  structure  of  the 
canal,  and  thence  penetrates  to  the  periosteum,  and  |)ursues  its 
course  backwards,  and  being  pent  up  beneath  the  dense  and 
inelastic  structures  there,  it   causes  excruciating  pain,  as   the 


AFFECTIONS    OF    THE    AUDITORY    CANAL.  299 

writer  has  seen  in  two  cases  of  the  kind.  The  protracted  contact 
of  .the  pus  with  the  surface  of  the  bone,  tends  to  destroy  the 
latter,  and,  as  result,  there  may  occur  necrosis  of  the  surface  of 
the  mastoid  bone,  and  penetration  of  pus  into  the  mastoid  cells. 

Treatment.— As  soon  as  this  osteo-periosteal  inflammation  of 
the  deeper  portion  of  the  auditory  canal  is  diagnosed,  which  may 
be  done  through  the  swelling  and  the  acute  and  widespread 
pain  about  the  ear,  Tillaux  counsels  to  locate  the  pain  by 
examination  with  an  aural  speculum,  and  to  freely  iucise  through 
the  swollen  wall  of  the  canal  to  the  bone;  thus  proceeding,  the 
inflammation  may  be  checked,  and  prevented  from  extending 
further.  Such  prophylactic  incision  can  rarely  be  made  early 
enough  to  arrest  the  inflammation  at  its  primary  site  of  appear- 
ance; as  a  rule,  the  surgeon  is  only  consulted  after  the  disease 
has  extended  its  sphere,  and  has  appeared  behind  the  ear.  At 
this  stage  it  must  likewise  be  met  by  a  free  incision  by  which 
the  swollen  structure  will  be  divided  to  the  bone,  and  free  escape 
provided  for  the  pus.  As  Tillaux  w^arns,  such  division  of  the 
parts  endangers  the  posterior  auricular  artery,  which  normally 
lies  in  the  bottom  of  the  furrow  between  the  ear  and  the  wall  of 
the  head.  Dissections  made  by  the  writer  of  this  region  have 
shown  that  this  location  is  not  unvarying.  The  vessel  is  some- 
times of  diminutive  calibre.  If  opened  by  the  incision,  the  firm 
and  resistant  tissues  in  which  the  vessel  lies,  renders  it  diflicult 
to  tie  or  twist  it;  and  hence,  as  Tillaux  directs,  if  it  be  opened,  it 
is  better  to  seize  the  divided  structure  in  which  the  artery  lies  in 
its  entirety  with  a  pair  of  compressing  forcejDs,  and  let  the  latter 
remain  in  place  for  some  hours.  A  plan  which  the  author  has 
pursued  is  to  make  a  vertical  cut,  somewhat  behind  the  site  of 
the  vessel,  reaching  to  the  bone.  Then  with  a  chisel  or  blunt 
dissector,  dissect  the  soft  j)arts  from  the  bones  towards  the  ear. 
In  this  way  a  free  outlet  is  made  for  the  escape  of  pus,  and  if  the 
dissecting  chisel  be  kept  in  contact  with  the  bone  underneath 
the  periosteum,  the  artery  will  be  uplifted  witli  the  soft  parts,  and 
will  not  be  opened. 

After  this  incision  has  been  made,  the  parts  which  are  the 
seat  of  suppuration,  should  be  washed  out  with  an  alcoholic 
sublimated  solution;  and  such  injected  fluid  will  commonly 
escape  through  the  meatus  by  an  opening  in  the  wall  of  the 
canal,  through  which  the  pus,  unaided,  has  established  an  outlet 
for  itself;  an  outlet,  however,  too  small  to  give  free  vent  to  the 
material.     The  connectien  between  this  opening  in  the  canal  and 


oOO  SUKGEKY  OF  TlIK  KXTKKXAL  EAR. 

the  purulent  collection  beliind  the  ear,  often  eludes  detection 
until  thus  verilied  by  injecting  fluid  from  the  incision.  The 
relief  which  is  allbrded  by  the  treatment  here  indicated  is  imme- 
diate; the  excruciating  agony  in  which  the  patient  writhed, 
vanished  in  a  few  minutes.  The  wound  made  must  be  kept  open 
for  some  days  by  means  of  lint  and  a  drainage  tube,  and  the 
whole  covered  with  lint  saturated  with  an  aseptic  solution.  And 
if  the  dressing  be  warm,  it  will  be  more  agreeable  to  the  patient 
than  if  it  be  maintained  cold.  If  this  osteo-peri osteal  inflamma- 
tion be  treated  early  in  the  way  here  detailed,  the  middle  ear 
will  escape  implication;  but  if  it  be  allowed  to  pursue  its  course 
untrammeled,  it  can  enter  the  tympanic  cavity  and  pass  thence 
into  the  mastoid  antrum;  and  in  this  form  it  attains  such 
intensity  that  it  passes  from  the  aural  apparatus  through  the 
intervening  wall  to  the  cranial  cavity,  and  there  becomes  the 
cause  of  fatal  disease;  hence  the  lesson  taught  of  early  and 
thorough  surgical  intervention  in  such  cases  of  osteo-peri  osteal 
inflammation. 

Ocdimon  of  the  Auditory  Canal. — The  canal  may  be  closed  by 
growths  adjacent,  which  coming  in  contact  with  the  canal,  finally 
close  it;  in  such  case  the  removal  of  the  growth  must  be  done  to 
restore  the  opening. 

The  meatus  has  been  closed  by  the  violent  use  of  nitrate  of 
silver,  by  whicli  granulations  were  caused  to  grow  and  become 
organized,  and  occlude  the  orifice.  Weintrach,  of  Vienna, 
described  such  cases  in  1870,  in  which  the  closure  had  thus  been 
intentionally  done  to  induce  deafness  for  the  purpose  of  avoiding 
military  duty.  In  these  cases  a  little  patriotism  might  be  pre- 
scribed as  a  prophylactic  against  such  mutilation. 

The  meatus  may  be  closed  by  an  os.seous  growth  developing 
there  and  finally  occluding  the  canal.  In  1879,  Delstanche  (fils) 
of  Brussels,  wrote  an  essay  on  such  exostosis,  of  which  he  collected 
twenty-five  cases. 

Delstanche  finds  that  this  growth  can  appear  both  before  and 
after  the  ossification  of  the  ear  is  complete.  As  causes  assigned 
are  heredity,  and  spontaneous  or  traumatic  inflammation;  also 
primary  or  secondary  inflammation  of  the  })eriosteum  and  bone. 
The  growth  occurs  in  all  parts  of  the  canal,  yet  it  is  oftenest 
noted  on  the  posterior  wall.  Symptoms  of  such  growth  are 
deafness  and  subjective  auditor}'  sensations;  likewise,  the  feeling 
of  pressure  and  vertigo;  all  of  which  is  duo  to  closure  of  the 
meatus. 


OCCLUSIOX    OF    THE    AUDITORY    CAXAL.  30l 

The  treatment  is  surgical  in  cljaracter  and  consists  in  the 
occasional  introduction  of  dilating  sounds,  and  tents  of  laminaria. 
One  may  also  bore  through  the  exostosis  and  chisel  it  off;  or  the 
removal  may  be  attempted  by  means  of  the  galvano-cautery,  or 
electrolysis.  In  one  case  Delstauche  removed  the  bone  by  boring 
a  part  of  the  way;  and  he  then  softened  the  remaining  wall  with 
chloride  of  zinc,  and  thus  removed  the  whole  of  it.  Some 
months  were  occupied  in  the  work,  yet  finally  the  bone  was 
entirely  removed,  and  hearing  perfectly  restored. 

Polypus  in  the  Auditory  Canal. — A  polypoid  growth  may  arise 
from  the  wall  of  the  canal,  from  the  outer  face  of  the  tynjpanic 
membrane,  or  from  the  wall  of  the  tympanum  itself;  the  first 
site  is  very  rare;  the  third  is  unusual,  while  the  polyp  springing 
from  themembrana  tympani  is  the  one  commonly  seen.  These 
growths  are  highly  vascular,  as  a  rule,  and  bleed  when  their 
surface  is  broken;  a  fact  to  be  borne  in  mind  when  their  extir- 
pation is  undertaken.  Methods  which  have  been  pursued  for 
their  removal  are  excision  with  small  curved  scissors,  cutting  off 
by  means  of  a  snare-like  wire,  and  plucking  out  by  means  of 
small  forceps.  Excision  is  rarely  practiced,  while  removal  by 
means  of  a  snare  devised  by  Wilde,  or  by  forceps,  are  the  methods 
in  common  use.  Simpler  cases  of  aural  polypus  may  be  treated 
by  the  surgeon;  since  the  work  of  removal  is  easily  done  by 
carefully  seizing  the  growth  with  forceps,  and  detaching  it  by 
traction  and  slight  torsion.  But  cases  which  are  deeply  seated,  or 
present  other  complication,  are  more  properly  committed  to  the 
aurist,  whose  special  training  has  given  him  dexterity  in  manip- 
ulation of  forceps  or  snare  in  the  auditory  canal. 

The  syphiloma  has  been  seen  in  the  auditory  canal ;  its  nature 
would  be  indicated  by  symptoms  of  secondary  syphilis  in  other 
parts  of  the  body.  Gruber,  in  his  study  of  syphilis  of  the  audi- 
tory apparatus,  finds  that  the  disease  more  often  attacks  the 
deeper  than  the  superficial  aural  structures.  In  all  such  cases 
the  constitutional  remedies  against  the  disease  should  be  admin- 
istered. 

Occlusion  of  the  Canal  by  Cerumen  or  Foreign  Bodies. — Cerumen, 
the  normal  secretion  of  glands  seated  on  the  cartilaginous  or 
outer  portion  of  the  auditory  canal,  may  accumulate  to  such 
amount  as  to  close  the  canal.  Though  the  ceruminous  matter  is 
generated  in  the  outer  two-thirds  of  the  passage,  yet  when  found 
in  large  amount,  it  is  always  situated  in  the  deeper  part  of  the 
canal   in    close  proximity  to,  or  in  contact  with,  the  tympanic 


uU2  yURGKRV  OF  THK  KXTKRXAL  EAR. 

lUL'Uibraiie.  A  large  mass  may  exist  and  not  be  suspected;  and 
it  is  only  when  tlie  closure  is  comi»lete  that  the  ear  is  deafened  a 
small  crevice  of  open  passage  to  the  membrana  tympani  sufiices 
for  the  purpose  of  normal  hearing;  let  the  closure  become  com- 
plete from  matter  added  to  the  mass,  or  let  the  walls  of  the  pas- 
sage swell  from  some  cause,  and  at  once  the  power  of  hearing  in 
that  ear  is  suspended.  Ceruminous  occlusion  of  the  ear  passage 
occurs  only  in  the  adult;  the  cliild  frequently  supplements  his 
exemption  by  closing  the  canal  with  some  foreign  body  just 
suited,  as  the  child  thinks,  to  stop  the  ear. 

The  history  of  the  case  as  told  by  the  patient,  often  enables 
the  surgeon  to  suspect  the  nature  of  the  trouble  before  he  has 
examined  the  ear;  by  the  aid  of  tlie  speculum,  or  by  looking 
into  the  ear,  when  the  pinna  has  been  drawn  upwards,  the  dark 
mass  of  cerumen  is  seen.  This  may  be  removed  by  means  of  a 
minute  tenaculum,  which,  being  hooked  into  the  outer  face,  the 
mass  is  drawn  out.  As  there  is  danger  in  thus  proceeding,  of 
forcing  the  matter  against  the  tympanic  membrane,  a  preferable 
method  is  to  inject  a  stream  of  tepid  water  into  tlie  open  portion 
of  the  canal;  thus  doing,  if  the  current  of  water  be  continued  for 
several  minutes,  the  mass  will  be  loosened  and  will  float  out. 
The  water  should  not  be  thrown  in  with  too  much  violence;  for 
by  such  imprudent  work  the  membrana  tympani  has  been  in- 
jured. If  the  impacted  material  still  remains  immovable  despite 
the  syringing,  then  an  effort  should  be  made  to  dissolve  it  by 
pouring  into  the  passage  an  alkaline  solution;  for  this,  lime 
water  or  a  weak  solution  of  carbonate  of  potash  may  be  used. 
The  solvent  power  of  the  solution  will  be  increased  by  the  addi- 
tion of  glycerine. 

In  persons  in  whom  there  is  a  disposition  to  frequent  recur- 
rence of  ceruminous  impaction,  the  trouble  may  depend  on  an 
abnormal  activity  of  the  producing  glands,  and  an  attempt 
should  be  made  in  such  cases  to  counteract  the  tendency;  for  this 
purpose,  an  alterative  remedy  should  be  locally  applied.  We 
may  select  one  of  the  following  recipes,  and  apply  it  in  the 
canal  with  a  camel-hair  brush,  making  the  application  once  in 
two  days: — 

H.    Tinctura?  lodi  Comi)Osita? 3ss 

Glycerini six 

Misce. 

1^.    Olei  AmygdaliL'  Expressi gss 

Olei  Cadini gj 

Misce. 


OCCLUSION    OF    THE    AUDITORY    CANAL.  303 

I^.    Unguenti  Hydrargyri  Nitratis 3ss 

Petrolati 5ss 

Misce. 
li.    Extracti  Ergotse  Fluid  i. 

Ichthyol aa  31 

Glycerin! gx 

Misce. 

1^.    Chrysarobini g^-  iij 

Petrolati oss 

Misce. 

The  topical  use  of  one  of  these  comjiounds,  applied  once  to 
the  passage  in  two  days,  with  irrigation  to  the  canal  with  warm 
water  on  the  intervening  days,  would  act  alteratively  on  the 
glands,  and  lessen  their  abnormal  activity. 

Foreign  Bodies  in  the  Auditory  Canal. — The  canal  of  the  outer 
ear  is  a  site  of  lodgment  of  small  foreign  bodies,  which  enter 
usually  by  accident  in  the  adult;  but  children,  inspired  by  the 
instinct  of  curiosity  and  the  desire  to  explore  the  passage,  push 
small  bodies  into  it ;  examples  of  such  foreign  bodies  are  beads, 
peas,  beans,  leaden  shot,  pebbles,  grains  of  wheat,  in  fact,  any 
small  object  with  which  the  child  is  accustomed  to  amuse  itself. 
Among  adults  such  accident  occurs  oftenest  with  those  who 
handle  hay  or  grain;  the  grain  of  oats,  the  beard  (arista)  of 
wheat,  oats  or  barley,  and  fragments  of  straw  are  not  unfre- 
quently  found  in  the  ear ;  and  remaining  there,  may  cause  much 
pain.  The  adult,  commonly  a  male,  may  be  quite  ignorant  of 
the  cause  of  the  trouble  of  his  ear,  for  which  he  seeks  advice,  and 
he  is  astonished  when  the  body  is  removed  and  shown  him. 

In  both  the  child  and  adult,  the  foreign  body  is  first  intro- 
duced into  the  outer  portion  of  the  canal;  and  situated  there,  it 
is  readily  removed  by  the  surgeon;  yet  usually  before  he  has 
been  consulted,  through  inadvertence  or  mismanagement,  the 
body  has  been  thrust  to  the  bottom  of  the  canal. 

Various  methods  of  extracting  foreign  bodies  from  the  outer 
canal  of  the  ear  were  known  and  practiced  by  the  Latin  physi- 
cians, as  is  evident  from  the  following  chapter  of  Celsus:  "Now 
and  then  something  is  accustomed  to  fall  into  the  ear,  such  as  a 
pebble  or  some  living  thing.  If  a  flea  has  entered,  there  should 
be  introduced  into  the  ear  a  little  wool;  and  if  the  flea  enters 
this,  the  wool  and  insect  are  to  be  withdrawn  together.  If  this 
has  not  succeeded,  or  there  be  some  other  small  animal  in  the 
ear,  a  probe  wrapped  in  woolis  to  be  dipped  into  some  resinous 


304  SURGERY  OF  THE  EXTERNAL  EAR. 

or  very  glutinous  material  (and  for  this  a  terebinthinate  sub- 
stance is  the  best);  and  the  probe  thus  armed  is  to  be  introduced 
into  the  ear  and  twisted  around;  thus  the  object  will  be  cauglit  and 
removed.  But  if  the  object  be  something  inanimate,  then  it  is  to 
be  drawn  out  with  an  ear  probe,  or  by  means  of  a  curved  hook; 
and  if  the  extraction  cannot  thus  be  done,  the  removal  may  be 
done  by  means  of  resinous  matter,  as  before  mentioned.  Agents 
wliicli  provoke  sneezing  being  used,  may  force  out  the  body; 
also,  water  thrown  into  the  ear  with  an  aural  syringe  may  force 
out  the  object.  Or  a  table  with  wings  adhering  to  each  side  may 
l)e  placed  in  position,  and  the  patient  tied  to  the  table,  with 
liis  head  lying  on  one  of  the  wings,  and  the  affected  ear  turned 
downwards;  while  the  subject  lies  thus,  let  the  wing  which  is  at 
the  feet  be  violently  struck;  thus  there  is  concussion  of  the  ear 
and  what  is  contained  in  it  drops  out."  The  surgery  of  modern 
times  gives  many  rules  for  the  removal  of  bodies  from  the  ear, 
the  suggestions  to  which  may  be  found  in  these  lines  of  Celsus. 

Should  the  patient  be  a  child,  the  facility  and  security  of  the 
work  will  be  promoted  by  first  administering  an  ancesthetic. 
And  before  commencing  the  work  of  extraction,  it  should  first  be 
certainly  determined  that  a  foreign  body  is  in  the  ear;  and  this 
can  be  done  by  the  aid  of  a  speculum  and  direct  or  reflected 
light.  When  the  object  is  once  seen,  there  is  no  risk  of  a  fruit- 
less search  for  something,  as  has  occurred  when  sucli  precaution 
was  neglected. 

Before  resorting  to  instruments,  the  Celsian  plan  of  concussion 
should  be  tried ;  for  this,  place  the  head  horizontally,  with  the 
ear  directed  downwards;  then  by  gravitation  the  body  may  fall 
out;  and  to  aid  this,  the  head  may  be  shaken. 

As  instruments  used  for  this  work  are  a  common  syringe,  a 
minute  curette,  and  a  small  tenaculum,  similar  to  that  used  in 
ophthalmic  surgery. 

In  almost  all  cases,  the  injection  of  water  into  the  passage  will 
dislodge  a  body  lodged  there ;  this  painless  and  simple  method 
should  be  tried  in  the  child,  in  preference  to  any  other;  for,  in 
this  way,  without  even  a  resort  to  an  ana}sthetic,  the  object  can 
be  removed,  especially  if  this  be  of  inorganic  material,  which 
cannot  enlarge  by  moisture.  As  has  previously  been  intimated, 
the  syringe  should  be  used  cautiously;  the  violent  force  of  water 
against  the  membrana  tympani  has  caused  fainting,  which 
might  be  perilous  if  the  patient  be  under  the  influence  of  an  an- 
aesthetic: likewise,  as  the  author  has  known,  the  violent  action  of 


FOREIGN    BODIES    IN    THE    AUDITORY    CANAL.  305 

the  v/ater  can  wound  the  membrane  itself.  If  the  body  be  a  seed 
or  grain  which  swells  in  germinating,  then  it  may  become  so 
wedged  in  between  the  walls  that  the  removal  is  very  difficult. 
If  the  injection  of  waterfalls  to  remove  the  body,  other  means 
must  be  tried.  Itard,  a  writer  on  this  subject,  advises  to  let  the 
seed  sprout,  and  then  extract  by  means  of  the  projecting  roots; 
he  has  omitted  to  state  whether  he  had  tried  his  plan;  his  advice 
is  probably  an  awkward  attempt  at  witticism.  To  remove  an 
impacted  se^d,  ansesthetize,  if  a  child,  and  then  through  a  bivalve 
speculum,  insert  a  tenaculum  in  the  body  and  extract.  If  an 
attempt  be  made  with  a  curette,  pass  this  along  the  upper  wall 
and  insinuate  it  above  and  behind  the  upper  end  of  the  object. 
This  is  facilitated  by  the  obtuse  angle  which  the  upper  wall 
makes  with  the  membrana  tympani. 

In  the  adult  the  object,  according  to  the  writer's  experience, 
is  oftenest  a  bearded  grain  of  oats,  or  the  beard  from  the  barley 
or  wheat  spike,  or  a  fragment  of  straw,  and  such  object  is  often 
held  in  place  by  becoming  entangled  in  cerumen.  As  a  rule  the 
object  can  easily  be  seized  with  a  pair  of  forceps  and  withdrawn; 
failing  thus,  one  can  resort  to  the  syringe.  In  both  adult  and 
child,  if  there  have  been  failure  to  remove  by  the  methods  given, 
the  receiving  end  of  a  rubber  syringe,  which  would  fill  the 
meatus,  might  be  introduced  and  a  vacuum  formed  by  which 
suction  could  be  made  on  the  body,  and  the  same  possibly  with- 
drawn. 

In  the  work  of  removing  objects  from  the  auditory  passage, 
the  careless  or  ill-adroit  hand  has  often  forced  the  body  against 
the  tympanic  membrane  and  perforated  it,  or  otherwise  injured 
its  delicate  structure.  Also  the  continued  contact  of  the  intruded 
body  can  open  the  membrane;  and  in  such  case  the  body  may 
enter  the  cavity  of  the  tympanum.  In  this  condition,  especially 
if  the  body  be  still  lodged  in  the  canal,  the  method  mentioned 
by  Celsus  of  inducing  sneezing  might  be  resorted  to,  thus  the  air, 
being  forced  backwards  through  the  Eustachian  tube,  might 
dislodge  the  object.  Or  sneezing  being  induced  and  the  mouth 
and  nose  being  closed,  as  directed  by  Paul  of  ^gina,  the  object 
might  be  sneezed  out  through  the  ear.  This  old  writer  says,  if 
one  has  not  succeeded  otherwise,  let  an  errhine  be  placed  in  the 
nose,  and  then  close  the  mouth  and  nose.  Thus  it  is  evident 
that  in  Celsus,  one  has  a  part  of,  and  in  Paul  of  ^gina,  the 
whole  of  the  procedure  of  Valsalva,  of  forcing  air  through  the 
Eustachian  tube. 


306  SI  KllKRY    OF    THE    EXTERNAL    EAK. 

Sliould  one  fail  to  remove  the  body  by  the  methods  described, 
the  pUiii  advised  by  Paul  of  .Egiiia  might  be  resorted  to,  viz., 
to  partly  detach  the  pinna  posteriorly,  and  thus  form  a  shorter 
road  to  the  body.  This  is  approved  by  the  anatomist  Ilyrtl, 
tlie  aurist  Troltsch,  and  the  surgeon  Tillaux.  To  do  this  Tillaux 
counsels  to  incise  posteriorly  and  su[)eriorly,  in  the  furrow 
between  the  ear  and  tlie  head,  keeping  close  to  the  mastoid 
bone.  By  this  incision  the  canal  is  opened  at  the  junction  of  the 
cartilaginous  and  osseous  portions.  Though  one  has  not  short- 
ened the  passage  much,  yet  a  more  direct  view  of  the  object  is 
thus  obtained.  Some  advantage  may  result  from  the  haem- 
orrhage from  the  cut,  as  thus  the  inflammation  caused  by  the 
body  is  combated. 

In  case  the  body  has  penetrated  the  middle  ear,  as  a  means  of 
removal  it  has  been  proposed  to  open  the  mastoid  process,  and 
thence  forcing  air  or  water  into  the  tympanum  exi)el  the  body. 
It  is  scarcely  probable  that  this  adventurous  method  will  be 
tried. 

HiTinorrhage  from  tJie  Auditory  Passage. — When  blood  flows 
from  the  ear  after  the  head  has  been  the  subject  of  violence,  as 
from  a  blow  or  a  fall,  it  is  a  matter  of  importance  to  determine 
the  origin  of  tha  blood:  is  its  source  extra-cranial  or  intra- 
cranial; or  does  it  issue  from  parts  both  inside  and  outside  of  the 
cranium?  If  its  source  be  from  inside  of  the  head  through  a 
fissure  from  fracture,  the  injury  is  one  which  menaces  life;  yet  if 
the  source  be  external,  the  injury  is  an  unimportant  one,  and  it 
then  can  arise  from  injury  of  one  or  more  of  the  following 
structures.  Violence  that  is  first  received  on  the  chin  may  be 
transmitted  along  the  lower  jaw  to  the  anterior  wall  of  the  auditory 
canal,  and  rupturing  the  lining  of  the  bone,  can  cause  bleeding. 
The  violence  may  also  reach  and  act  on  the  tym})anic  membrane; 
this  membrane  contains,  both  in  its  outer  and  inner  surface, 
arterioles,  derived  chiefly  from  the  internal  maxillary  artery,  and 
in  the  membrane  the}''  lie  alongside  of  the  handle  of  the  malleus. 
From  a  rupture  of  these  vessels  as  observed  by  Tillaux  and 
Duplay,  a  considerable  bleeding  can  originate.  Also  from  a 
rupture  of  the  mucous  lining  of  the  walls  of  the  tympanum 
haemorrhage  can  arise.  And  finally  from  fracture  of  the  mastoid 
portion  of  the  temporal  bone  l)lood  may  pass  into  the  tvmpanum 
and  escape  through  its  membrane  if  that  be  torn ;  or  if  the 
membrane  be  intact,  the  blood  may  flow  into  the  tliroat  through 
the  Eustacliian  tube.     Le  Bail,  Duplay  and  others  have  made  a 


HAEMORRHAGE    FROM    THE    AUDITORY    PASSAGE.  307 

careful  study  of  these  points,  and  have  shown  that  after  injury  of 
the  head,  bleeding  from  the  ear  may  proceed  from  some  of  the 
superficial  sources  here  enumerated.  It  must  however  be  men- 
tioned that  though  it  arise  thus  superficially,  the  bleeding  may 
arise  from  a  fracture  of  the  cranium  at  or  near  its  base;  thus  a 
fracture  of  the  petrous  bone  may  open  the  carotid  artery,  and 
violent  bleeding  take  place  into  the  middle  ear;  such  injury 
would  be  perilous,  and  would  probably  soon  be  followed  by  grave 
encephalic  trouble;  yet  if  the  haemorrhage  originated  superficially, 
it  would  soon  cease,  and  be  accompanied  by  no  symptom  indi- 
cating danger. 

In  fracture  of  the  base  of  the  skull  in  which  the  petrous 
part  of  the  temporal  is  broken,  though  primarily  there  may  be 
an  escape  of  blood,  yet  this  may  soon  cease,  and  instead,  a  serous 
fluid  may  continue  to  flow  from  the  ear  ;  the  origin  of  the  serum- 
like fluid  has  been  a  matter  of  discussion. 

This  discharge  of  fluid  resembling  serum  has  been  carefully 
studied  by  Laugier,  and  his  observations  have  been  confirmed  by 
Nelaton,  Chassaignac,  Guthrie  and  others.  The  fluid  is  at  first 
stained  with  blood,  yet  later  it  becomes  nearly  colorless,  and  may 
vary  in  amount  from  an  ounce  to  as  much  as  two  pints.  A  similar 
escape  of  fluid  has  been  observed  from  the  nose  in  injury  of  the 
cranium.  The  hearing  may  remain  intact  while  such  fluid  is 
escaping. 

Some  five  theories  have  been  ofiered  to  explain  this  discharge. 
It  has  been  claimed  that  it  originates  from  the  internal  ear,  and 
is  the  liquid  of  Cotunnius;  the  enormous  quantity  often  seen 
disproves  this  opinion,  and  especially  so  when  the  escape  is  from 
the  nose,  as  often  occurs.  Laugier  erred  in  referring  the  source 
to  a  clot  of  blood  lodged  between  the  meninges  and  the  adjacent 
bone,  whence  the  serous  content  escaped;  and  this  was  again  dis- 
proven  by  the  small  volume  of  such  clot,  and  the  absence  of 
compression,  which  such  coagulum  must  cause:  and  the  analysis 
of  the  fluid  made  by  Chatin,  which  revealed  a  great  difference 
between  the  composition  of  this  fluid  and  the  serum  of  the  blood, 
quite  disproved  the  notion  that  such  fluid  is  derived  from  a  clot. 
And  a  similar  objection  can  be  urged  against  the  opinion  of 
Chassaignac  that  the  fluid  is  from  veins  of  which  the  walls  have 
been  thinned  by  stretching  or  tearing.  Guthrie  believed  the 
source  of  the  fluid  to  be  the  arachnoid  membrane.  The  true 
source  of  this  fluid  is  the  liquor  cerebro-spinalis;  the  arachnoidean 
cavity  containing   this  is  opened  at  a    dependent  point,  where 


308  SURGERY  OF  THK  EXTERNAL  EAR. 

the  auditory  nerve  enters  tlie  internal  auditory  meatus,  and 
thence  tlirough  a  fissure  it  may  reach  the  middle  ear.  Besides 
this  route  ingeniously  traced  out  l)y  IVrard,  it  is  probable  that 
the  thin  bony  roof  of  the  tympanic  cavity  might  be  fractured  and 
the  fluid  find  egress  there. 

Concerning  the  intra-cranial  source  of  such  fluid,  there  can  be 
no  such  doubt  as  is  often  the  case  concerning  blood  escaping  from 
the  ear,  since  in  respect  to  the  former  there  is  no  other  fluid  with 
which  it  could  be  confounded. 

Mastoid  Cavity. — The  cellular  antrum  of  the  mastoid  portion 
of  the  temporal  bone  is  an  important  appendage  to  the  middle  ear, 
which  in  recent  times  has  become  one  of  the  added  fields  of  sur- 
gical occupation:  or  it  may  more  properly  be  said,  a  section  which 
having  once  been  abandoned,  has  been  reclaimed;  for,  as  early 
as  1770,  Ja.sser  opened  the  mastoid  antrum,  so  as  to  have  a  .shorter 
road  to  the  tympanum,  through  which  injections  could  be  made 
to  remove  obstruction  in  the  Eustachian  tube:  and,  at  the  same 
period,  it  appears  to  have  been  done  to  obtain  a  more  direct  open- 
ing into  the  tympanum  than  the  Eustachian  tube,  in  case  of 
deafness  from  closure  of  the  latter;  and  with  this  object  the 
mastoid  cells  were  opened  by  Jasser,  in  the  case  of  Just  Berger, 
the  royal  Danish  physician;  but  as  the  operation  caused  his 
death,  the  procedure  was  quickly  abandoned,  and  for  more  than 
half  a  century  afterwards,  there  are  recorded  but  three  cases  in 
which  the  operation  was  done.  In  1847  Dieffenbach  speaks  of 
trej)hining  the  mastoid  process  as  an  operation  which  has  been 
abandoned,  and  he  says  that  it  should  be  stricken  from  the  list  of 
surgical  operations.  About  18G0,  however,  the  operation  was 
resumed  again;  and,  due  to  the  efforts  of  Schwartze,  Pean.  Buck, 
Schede  and  otliers,  it  has  been  given  a  merited  and  an  enduring 
place  in  operative  surgery. 

Some  anatomical  description  should  be  jjremised  of  the  bony 
structure  in  which  the  mastoid  cells  are  lodged. 

Externally,  the  cells  are  bounded  by  a  wall  of  bone  which 
se[)arates  them  from  the  skin,  and  the  thickness  of  this  wall 
varies  from  one  to  three  lines;  and  according  to  Huschke  this 
difference  is  not  dependent  on  age,sex,or  the  volume  of  the  mastoid 
process.  Tillaux,  however,  finds  it  dependent  on  age,  and  that 
in  the  old  person,  it  may  be  reduced  to  extreme  thickness.  The 
inner  wall,  a  thin  glass-like  plate,  has  close  relations  with  the 
lateral  sinus;  relations  which  luive  been  fatally  learned  by  the 
indiscreet  trephine;  for  through  this  wall  venules  pass  to  the 


MASTOID    CAVITY,  309 

sinus,  along  which  disease  may  travel  from  the  affected  cells, 
and  cause  phlebitis  and  thrombus.  The  sinus  lies  on  the 
inner  face  of  the  mastoid  process,  and  nearest  to  its  anterior 
border.     (Tillaux.) 

In  front,  the  mastoid  cells  are  separated  from  the  auditory 
canal  by  a  layer  of  compact  tissue,  and  the  relations  witli  the 
canal  and  tympanum  are  such  that  pus  can  escape  from  the 
antrum  into  the  auditory  canal  without  entering  the  tyrnj^anum; 
and  conversely,  pus  developed  in  the  canal  can  pass  through  this 
anterior  wall  into  the  mastoid  antrum,  and  thence  travel  into  tlie 
cranium. 

With  these  topographical  conditions,  as  Tillaux  has  pointed 
out,  pus  in  the  mastoid  region  may  have  the  following  situa- 
tions: pus  may  originate  on  the  outer  wall  of  the  mastoid  cells 
and  afterwards  traverse  the  wall  and  appear  inside.  In  a  second 
form,  the  pus  may  pass  from  the  tympanum  into  the  cells.  Or 
the  pus  from  one  of  these  sources  may  penetrate  the  inner  wall 
and  attack  the  encephalic  structures:  hence,  as  to  site,  the  pus 
may  be  extra-mastoicl,  intra-mastoid  or  intra-cranial. 

Whatever  situation  the  purulent  collection  may  occupy,  the 
proper  treatment  is  to  make  a  free  opening  through  which  the 
pus  can  be  evacuated;  and  for  this  work  the  services  of  the 
general  surgeon  will  sometimes  be  invoked.  The  indication  is 
urgent  and  imperative;  for  if  the  diseased  material  once  traverses 
the  thin  plate  which  separates  it  from  the  brain,  the  patient's  life 
is  often  lost.  All  those  operated  on,  however,  do  not  recover: 
Poinsot  has  made  a  collection  of  ninety-one  cases  in  which  the 
mastoid  bone  was  opened  for  the  liberation  of  pus;  of  these  fifteen 
died  and  seventy-one  were  cured.  These  figures  justify  the  oper- 
ation, even  though  some  of  the  cases  might  have  recovered  with- 
out surgical  intervention.  Still  non-interference  is  unwise,  for 
nature,  possessed  as  she  is  of  unlimited  time  for  her  work,  too 
often  appears  too  tardily  on  the  scene  with  relief;  the  lethal  work 
of  disease  has  been  completed  through  the  pus  seeking  an  intra- 
cranial route  rather  than  an  extra-cranial  outlet. 

The  work  of  opening  the  mastoid  cells  has  been  done  with 
the  gouge,  the  drill,  the  trephine,  and  the  chisel  and  mallet;  the 
gouge,  chisel  and  mallet  are  the  best;  though  in  cases  in  which  the 
wall  is  very  thin,  the  opening  might  be  made  with  any  species  of 
cutting  instrument. 

The  operators,  though  in  accord  in  reference  to  carefully 
shunning  the  lateral  sinus,  do  not  agree  in  reference  to  the  point 


310  SURGERY    OF    THE    EXTERNAL    EAR. 

cit  whic'li  tliiscan  best  l)e  done.  Ilyrtl  directs  to  open  tlie  exter- 
nal face  of  the  mastoid  process,  and  not  to  open  heliind  this, 
though  the  latter  structure  is  properly  the  mastoid  portion  of 
the  temporal  bone.  This  is  directly  the  contrary  of  the  advice  of 
Tillaux,  who  says  that  the  lateral  sinus  corresponds  in  the  cranium 
to  the  anterior  border  of  the  mastoid  process.  Poinsot,  who  has 
written  extensively  on  this  subject,  counsels  to  do  the  work  by 
first  making  a  crucial  cut  through  the  soft  parts;  namely,  a 
vertical  cut  over  two  inches  long,  is  to  begin  at  the  temporal 
ridge,  and  thence  downwards;  tliis  is  to  lie  about  a  half  inch 
behind  the  concha.  The  vertical  incision  is  to  be  intersected  by 
a  horizontal  cut  which  lies  on  a  level  with  the  superior  wall  of 
the  auditory  canal.  In  this  work  a  branch  of  the  ])Osterior 
auricular  arterj'  may  V)e  severed  and  require  torsion  or  ligation. 
At  the  point  of  intersection  of  the  two  cuts,  according  to 
Desarenes,  one  finds  near  the  posterior  root  of  tlie  zygomatic 
process,  a  slight  depression  in  tlie  bone,  which,  he  thinks,  is  the 
proper  point  for  opening  the  wall.  Should,  however,  there  be 
discovered  a  disease  point  in  the  wall  elsewhere,  this,  of  course, 
should  be  selected  for  the  opening.  But  wdiatever  site  may  be 
selected,  the  orifice  made  should  have  a  direction  inwards,  for- 
wards, and  slightly  upwards,  a  direction  parallel  with  the  audi- 
tory canal.  The  opening  must  be  made  with  care,  especially  as 
one  reaches  the  inner  wall.  With  whatever  instrument  it  is  done, 
the  outlet  must  bo  sufficient  for  the  free  escape  of  the  purulent 
matter:  and  this  eidargement  of  the  opening  is  readily  done  with 
small  exsecting  forceps,  of  which  a  good  one  may  be  found  among 
forceps  used  in  dentistry.  Since  the  cells,  the  site  of  suppuration, 
do  not  intercommunicate  freely,  these  should  be  broken  down  so 
that  tlie  part  can  be  perfectly  evacuated.  The  cavity  thus 
opened  must  be  irrigated  daily  with  some  aseptic  fluid;  carbol- 
ized  or  alcoholized  water  may  be  used.  During  tlie  period  of 
separation,  a  drainage  tube  must  be  retained  in  the  opening.  A 
number  of  weeks,  or  even  months,  maybe  required  to  complete 
the  cure.  The  wound,  during  the  period  that  it  is  kept  open,  is 
the  site  of  an  exuberant  granulative  growth,  which  must  be 
repressed  by  potential  cauterization.  Nevertheless,  after  the 
closure,  a  iibrous  neoplasm  may  a[)pear  on  the  site  of  the  previous 
wound:  a  neoplasm  resemljling  keloid  and  ver}^  difficult  to 
remove;  for,  as  the  writer  has  verified  in  a  case  treated  by  him, 
despite  radical  removal  by  the  knife,  like  a  keloid  growth,  the 
neoplasm  soon  reappeared.    In  sucli  a  case  non-intervention  would 


EMPHYSEMA    IN    MASTOID    REGION.  311 

be  the  better  course,  especially  as  the  post-auricular  site  of  such 
growth  conceals  it  from  view. 

Ill  the  scrofulous  child  suppurative  action  of  lymphatic 
glands  seated  on  the  mastoid  process  may  implicate  the  latter, 
and  terminate  in  necrosis  of  a  large  part,  or  of  the  entirety  of  the 
mastoid  process.  The  author  has  seen  instances  of  this:  in  one, 
the  entire  process  became  necrosed  and  was  removed.  The  hear- 
ing was  not  affected;  but  there  remained  a  slight  degree  of  torti-« 
collis. 

The  mastoid  process  has  been  fractured  by  a  bullet;  such  a 
case  was  seen  by  Dupuytren.  The  sterno-cleido-mastoid  being 
inserted  into  this  bone  would  tend  to  displace  the  fragment  down- 
wards; acting  similarly  to  the  triceps  extensor  cubiti,  or  quadri- 
ceps extensor  cruris  in  fracture  respectively  of  the  olecranon  and 
patella.  There  would  be,  after  such  displacement,  much  diffi- 
culty in  maintaining  coaptation  of  the  parts.  A  bandage,  as 
suggested  by  Hyrtl,  would  not  accomplish  the  purpose.  A  plan 
which  might  succeed  would  be  myotomy  done  near  the  upper 
end  of  the  muscle.  A  more  certain  means  of  maintaining  union 
would  be  by  metallic  ligature.  This  could  be  used  here  more 
easily  than  in  the  case  of  fractured  olecranon  and  patella,  in  which 
it  has  been  employed;  in  the  former  fracture,' there  is  no  joint 
which  would  be  endangered,  like  that  of  the  elbow  or  knee.  For 
metallic  suture,  first  drill  a  canal  from  above  downwards,  which 
beginning  above  in  the  mastoid  process  shall  traverse  a  section 
of  this  bone,  and  be  continued  longitudinally  through  the  frag- 
ment below;  through  this  canal,  a  wire  may  be  passed  by  which 
coaptation  can  be  effected,  and  union  secured:  treatment  analo- 
gous to  that  sometimes  pursued  in  cases  of  ununited  fracture. 

Emphysema,  called  also  Pnemnatocephalus,  situated  in  the  mas- 
toid region. — The  external  wall  of  the  mastoid  portion  of  the 
temporal  bone  is  often  extremely  thin,  as  has  been  pointed  out  by 
Hyrtl;  and  to  an  opening  through  this  is  due  the  occasional 
appearance  of  a  collection  of  air  beneath  the  scalp,  which  is 
similar  to  a  gaseous  accumulation  in  the  soft  parts  elsewhere, 
and  has  been  named  here  pnemnatocephalus,  and  also  pneumat- 
ocele. 

Though  air  may  escape  from  the  mastoid  antrum  in  conse- 
quence of  a  fracture  of  the  wall,  and  insinuate  itself  beneath  the 
scalp,  yet  pneumatocephalus  proper  is  that  form  of  trouble  in 
which  a  tumor  containing  air  has  appeared  without  any  antece- 
dent fracture.     In  such  case,  through  a  weak  point,  or  an  opening 


312  SURGERY  OF  THE  EXTKRXAL  EAR. 

in  the  outer  wall,  existing  congenitally,  the  air  is  forced  from  the 
throat  into  the  niicUlle  ear,  and  thence  into  the  mastoid  antrum; 
'  and  through  the  defect  in  the  mastoid  wall  the  air  appears 
beneath  the  soft  parts.  For  this  to  occur,  strong  expiratory  effort 
is  required,  as  in  coughing,  sneezing,  and  blowing  the  nose. 

Costes  of  Bourdeaux,  in  1859,  seems  to  have  first  observed 
pneumatocephalus;  in  1865,  Tliomas  of  Tours  described  it  as  a 
.tumor  of  irregular  surface,  situated  behind  the  ear,  and  which, 
by  pressure,  is  reducible,  and  can  thus  be  caused  to  disappear. 
As  it  disappears,  the  escaping  air  can  be  heard  in  the  ear,  and 
perceived  passing  into  the  throat.  A  similar  collection  of  air 
can  appear  on  the  frontal  region,  arising  from  fracture  or  defect 
in  the  outer  wall  of  the  frontal  sinus.  By  far  the  greater  number 
of  cases  of  pneumatocele  which  have  been  recorded  were  situated 
in  the  mastoid  region.  In  all  these  cases,  the  tumor  occui)ied 
only  the  upper  portion  of  the  mastoid  bone,  and  extended  thence 
upwards  towards  the  summit  of  the  cranium. 

Besides  deforming  the  head  by  its  volume,  the  pneumatocele 
becomes  a  source  of  inconvenience  to  its  possessor  through  the 
whistling  sound  which  arises  from  the  escaping  air  wdien  the 
patient  rests  his  head  on  the  affected  side.  The  variable  volume 
of  the  tumor,  its  temporary'  disappearance  under  compression, 
and  the  roaring  or  whistling  sound  which  arises  from  pressure, 
are  symptoms  which  denote  the  character  of  the  tumor. 

Treatment — As  the  tumor  tends  to  advance  rather  than  to 
recede  in  volume,  an  attempt  should  be  made  to  obliterate  it:  as 
methods  to  effect  this,  the  following  have  been  tried:  compression, 
seton,  incision,  and  the  injection  of  iodine.  Compression  is 
similar  to  all  other  means  in  medicine  which  cannot  harm,  yet 
are  incapable  of  doing  much  good;  jjueuraatocephalus  has  been 
relieved,  but  not  cured,  by  pressure.  Adhesion  must  be  obtained 
between  the  bone  and  the  uplifted  scali>,  else  the  air  will  enter 
and  refill  the  cavity.  Some  inflammatory  action  must  be  awak- 
ened. The  seton  has  been  tried;  but  here,  as  in  other  cases,  the 
irritation  excited  is  too  limited.  To  do  the  work  more  thoroughly 
the  cavity  has  been  laid  open  by  a  free  incision,  with  the  view  of 
obliteration  through  suppuration  and  granulative  action.  The 
work  thus  done  was  too  thoroughly  done;  a  case  thus  treated 
ended  fatally,  through  the  inflammatory  action  extending  tlirough 
the  cranial  wall,  and  causing  meningo-encephalitis.  Hence 
incision  is  perilous  and,  as  a  safer  method,  recourse  has  been  had 
to  injections  of  the  tincture  of  iodine;  in  this  way  pneumato- 
cephalus has  been  successfully  treated. 


EMPHYSEMA    IN    MASTOID    REGION.  313 

111  the  concluding  section  to  this  chapter  on  the  surgical 
affections  of  the  ear,  the  writer  will  refer  to  a  class  of  cases  in 
which  suppurative  action  beginning  in  the  tympanic  cavity,  or 
mastoid  cells,  has  passed  into  the  cranial  cavity.  Such  pus  in 
its  intra-cranial  immigration  might  pass  upwards  and  appear  in 
front  of  the  petrous  portion  of  the  temporal  bone;  or  it  might 
appear  external  to  or  contiguous  to  the  lateral  sinus ;  or  it  might 
travel  behind  the  lateral  sinus,  and  affect  the  cerebellar  portion 
of  the  brain ;  that  is,  pus  forming  in  the  middle  ear  might  enter 
the  middle  cranial  fossa,  and  involve  the  contiguous  cerebrum 
with  its  membranes;  or  it  might  appear  in  the  posterior  fossa 
and  involve  structures  beneath  the  tentorium.  Pus  in  these 
positions,,  if  in  large  amount,  would  cause  symptoms  of  cerebral 
compression:  there  would  be  mental  unconsciousness,  coma,  a 
slow  full  pulse  and  probably  dilatation  of  the  pupils.  With 
such  symptoms,  if  trephining  the  mastoid  process  did  not  detect 
pus,  one  would  be  justified  in  pursuing  the  search  further,  viz., 
to  seek  for  pus  inside  of  the  skull,  by  opening  the  wall.  For  this 
purpose,  lay  bare  the  skull  above  the  mastoid  bone,  and  apply  a 
trephine  above  the  superior  root  of  the  zygomatic  process,  viz., 
above  that  ridge  which  is  continuous  with  the  temporal  ridge. 
An  opening  could  be  safely  made  here  ;  and  through  such 
fenestra  one  could  examine  and  determine  the  condition  of 
structures  which  lie  in  the  petroso-squamous  interspace;  and 
also  the  search  might  be  continued  inwards  over  the  roof  of  the 
tympanum,  through  which  disease  sometimes  passes  into  the 
skull.  Such  explorations  can  readily  be  done  by  detaching  and 
uplifting  the  membranes  with  a  blunt  dissector.  Should  no  pus 
be  found,  and  yet  the  membranes  present  signs  of  disease,  an 
opening  should  be  made  in  the  latter,  through  which,  if  pus  be 
discovered,  an  outlet  will  be  provided  through  which  the  con- 
cealed material  can  escape.  If  the  search  for  purulent  material 
prove  fruitless  at  this  point  in  the  squamous  portion  of  the 
temporal  bone,  then  an  opening  should  be  made  through  the 
suture  which  separates  the  mastoid  from  the  occipital  bone;  here 
there  would  be  some  risk  of  injuring  the  lateral  sinus.  By  such 
exploratory  trephination,  intra-cranial  pus  whether  of  tympanic 
or  mastoid  origin  might  be  found,  and  an  outlet  for  it  furnished. 
If  pus  be  found,  the  site  of  it  should  be  antiseptically  irrigated, 
and  free  drainage  be  provided  through  a  tube,  and  downward 
lateral  position  of  the  head.  In  this  unusual  manner  of  proceed- 
ing some  opportunity  would  be  offered  to  the  patient  of  saving 
21 


314  SURGERY    OF    THE    EXTERNAL    KAK. 

his  life,  wliich,  without  surgical  interference,  would  certainly  be 
lost. 

In  former  days,  when  penetration  of  the  cranial  wall  and 
search  for  disease  were  forbidden  or  neglected,  the  writer  recalls 
fatal  cases  in  which  the  procedure  here  advised  would  have 
offered  the  patient  a  chance  to  escape  from  death.  Some  work  in 
this,  but  little  trodden,  field  has  .successfully  been  done  by  Mac- 
Ewen :  work  original  and  of  great  interest,  and  reflecting  high 
credit  on  its  author.  Under  his  guidance,  no  one  need  hereafter 
dread  the  dural  sinuses. 


CHAPTER   Vlir. 


SUKGERY  OP  THE  FRONTAL  REGION. 


Frontal  Region. — The  frontal  region,  bounded  above  and 
laterally  by  the  hair,  and  below  by  the  occular  cavities  and  the 
nasal  region,  is  the  seat  of  a  number  of  surgical  affections,  and 
these,  proceeding  from  without  inwards,  are  located  in  the  skin, 
the  periosteum,  and  the  bone. 

In  the  skin  during  the  evolution  of  puberty,  and  continuing 
a  few  years  afterwards,  the  sebaceous  glands  are  often  the  site  of 
abnormal  activity,  in  the  form  of  acnaceous  eru]:)tion.  Sebaceous 
acne  bears  a  resemblance  to  the  atheromatous  cyst;  the  former  is 
a  miniature  model  of  the  latter;  and  the  opening  which  maybe 
found  in  each,  is  of  similar  size.  Acne,  though  occurring  on  the 
cheeks,  is  especially  conspicuous  on  the  forehead,  and  from  tlie 
unsightly  appearance  which  it  gives  the  forehead,  it  becomes  a 
source  of  sorrow  to  its  youthful  possessors:  a  sorrow  that  the  mir- 
ror multiplies;  and  though  time  will  eventually  relieve  him  of 
his  anguish,  yet  that  method  of  relief  is  too  tardy  for  youth;  so 
that  physician,  surgeon,  and  specialist  are  often  appealed  to. 

Treatment. — A  simple  means  of  relief,  and  sometimes  cure  of 
this  affection,  is  the  use  of  strongly  alkaline  soap,  such  as  is  often 
manufactured  in  the  farmhouse.  An  article  similar  to  this  is  a 
species  of  soap  sold  by  the  cliemist  under  the  name  of  German 
green  soap.  Let  either  of  these  articles  be  rubbed  well  on  the 
affected  parts  at  night;  and  on  the  following  morning  let  this  be 
washed  off.  A  repetition  of  this  application  a  few  times  often 
removes  the  acnaceous  points.  Another  remedy  that  may  be 
employed  for  the  same  purpose  is  corrosive  sublimate  in  an  emul- 
sion of  sweet  almonds,  viz.,  in  the  proportion  of  two  grains  of  the 
sublimate  to  an  ounce  of  the  emulsion;  this  should  be  applied 
twice  a  day.  A  third  remedy  is  an  ointment  of  calomel,  viz.,  five 
grains  of  the  submuriate  of  mercury  to  an  ounce  of  spermaceti 
ointment,  applied  twice  daily.     These  local  remedies  are  preferable 

(315)   .    • 


31G  SURGERY    OF  THE    FRONTAL    REGION. 

to  the  methods,  sometimes  adopted,  of  pressing  out  tlie  hardened 
sebum,  or  of  splitting  the  cup-shaped  cavity  and  expressing  the 
contents. 

The  frontal  integument  is  the  site  of  benign  and  malignant 
growths;  the  latter  class  is  so  rarely  seen  here  that  our  attention 
will  be  limited  to  a  consideration  only  of  the  benign  neoplasm. 

The  verrucose  or  warty  growth  seldom  appears  on  the  frontal 
integument;  yet  it  may  do  so,  and  is  then  most  frequently  where 
the  hairless  skin  meets  the  scalp  ;  and  the  site  there  may  inter- 
fere with  the  head-dress.  The  removal  of-  such  growth  is  best 
done  by  means  of  a  circumscribing  incision,  which,  to  be  effectual, 
must  reach  quite  through  the  derm.  If  the  gap  made  be  large, 
it  should  be  closed  by  a  suture. 

Lipoma  frequently  occurs  in  the  integument  of  the  frontal 
region,  and  is  usually  of  the  fibrous  species,  in  which  fibrous 
tissue  is  the  predominant  element  of  the  growth.  The  most 
ordinary  site  of  this  growth  is  on  the  frontal  tuberosity,  and  its 
origin  there  is  probably  due  to  the  long-continued  pressure  of  the 
hat,  or  some  article  of  head-dress.  It  is  oftener  seen  in  the  male, 
doubtless  referable  to  the  weight  and  pressure  of  the  hat  on  the 
upper  part  of  the  forehead.  If  such  growth  attains  a  volume 
which  interferes  with  the  dress  of  the  head,  it  should  be  removed. 
For  this  i:)urpose  an  incision,  directed  horizontally  or  vertically, 
should  be  made  through  the  skin  to  the  growth,  and  when  this  is 
reached,  it  is  to  be  uplifted  with  a  tenaculum  and  dissected  from 
the  under  surface  of  the  skin,  to  which  it  is  closely  adherent.  And 
this  detachment  is  tedious,  owing  to  the  close  adherence  of  the 
skin  to  the  tumor,  which  in  flattened  form,  due  to  pressure,  is 
intimately  joined  to  the  skin;  in  fact,  this  adherence  to,  and  fusion 
with,  the  skin  is  the  distinguishing  characteristic  of  the  frontal 
fibro-lipoma.  The  connecting  bands  of  adhesion  must  be  patiently 
cut  asunder  with  scissors  or  scalpel;  for  it  cannot  be  rapidly 
lifted  out  of  its  recess,  as  one  does  with  the  normal  lipoma.  The 
irregular  wound  made  by  such  dissection  does  not  heal  rapidly, 
as  a  rule,  and  will  require  much  care  in  dressing  to  avoid  an 
unsightly  scar.  Since  the  site  of  this  scar  is  such  as  to  render  it 
conspicuous,  the  operator  must  study  to  lessen  and  conceal  it  as 
much  as  possible,  and  to  do  this  the  line  of  incision  should  be  in 
one  of  tiie  wrinkles  or  furrows  which  often  exist  in  the  frontal 
tegument;  and  since  the  vertical  or  horizontal  furrows  may  pre- 
dominate in  depth,  the  deeper  one  should  be  chosen  for  the  incis- 
ion; usually  this  can  best  be  done  horizontally. 


FRONTAL    REGION.  317 

The  angioma  often  occurs  congenitally  in  the  frontal  region ; 
and  the  vascular  growth  presents  itself  in  various  forms;  there 
may  be  only  a  miniature  point,  or  it  may  embrace  a  large  space ; 
it  may  be  definitely  bounded,  or,  without  clear  limit,  it  may  vanish 
insensibly  in  the  adjacent  structure.  It  may  be  venous  in  struc- 
ture, or  arterial  and  venous  elements  may  be  intermingled.  It 
may  be  situated  only  in  the  surface  of  the  skin,  in  the  form  of  the 
so-called  wine-mark;  or  it  may  occupy  the  papillary  structure 
of  the  derm,  or  it  may  extend  quite  through  the  skin.  Varicose 
dilatation  seldom  occurs  here.  Appearing  as  a  speck  in  the  new- 
born child,  it  may  soon  grow,  and,  in  a  few  months,  spread  over 
a  large  surface.  Within  eight  months  more  than  half  of  the 
frontal  region  was  occupied  by  the  vascular  growth,  in  a  case 
seen  by  the  writer.  Again,  having  attained  wide  dimension,  it 
may  cease  to  grow,  and  may  even  recede  and  vanish. 

For  further  description  of  the  angioma  and  of  the  means 
employed  for  its  extinction,  the  reader  is  referred  to  a  previous 
chapter  of  this  work,  in  which  this  subject  has  been  fully  con- 
sidered. 

The  frontal  wall  of  the  cranium  is  the  occasional  site  of 
exostosis;  and  this  may  spring  from  the  outer  plate,  or  from  the 
diploetic  structure.  Such  osseous  growth  has  been  found  most 
frequently  at  the  site  of  the  frontal  tuberosities,  or  near  the  junc- 
tion of  the  frontal,  ethmoid  and  superior  maxillary  bones;  and 
in  this  latter  situation  the  osteal  growth  can  encroach  on  the 
orbit.  Such  growth  demands  surgical  aid,  both  to  free  its  pos- 
sessor of  deformity,  and  of  obstructioi^^to  the  subject's  head-dress. 

The  exostosis,  here  as  elsewhere,  must  be  excised  from  its  parent 
bone;  and  to  guard  against  re-growth,  the  excision  must  include 
the  external  plate  of  the  cranial  wall,  and  should  reach  slightly 
beyond  the  growth.  If  the  section  made  be  a  smooth  one,  the 
wound  will  heal  quickly,  with  but  slight  scarring. 

The  secondary  manifestations  of  syphilis  seem  to  have  .a 
preference  for  the  frontal  region  as  field  for  their  development. 
In  the  dermal  structures  Venus  displays  the  elements  of  her 
varying  coronal  chaplet  in  the  diverse  forms  of  rashes  which, 
enumerated  in  climacteric  order,  are  maculated,  papular,  squa- 
mous, vesicular  and  pustular.  After  these  eruptions  have  taken 
possession  of  the  surface,  the  disease,  like  a  Messalina,  in  orderly 
disorder  revels  in  riot,  and  seeks  ground  for  further  occupancy 
in  the  deeper  structures,  in  the  form  of  the  syphiloma  or 
gummatous  tumor.       The  gummatous  growth  develops  within 


318  SURGERY    OF    THE    FRONTAL    REGION. 

the  derm,  tlie  pericranium,  the  bony  wall,  and  then,  if  followed, 
it  may  be  found  in  the  dura  mater  and  brain. 

The  superficial  syphilides,  if  tlie  patient  receive  early  and 
proper  treatment,  will  vanish  and  leave  no  trace;  but  neglected 
until  the  pustules  have  destroyed  the  surface  and  ended  in  ulcer- 
ation, then,  though  the  disease  be  controlled  by  treatment, 
enduring  vestiges  of  it  will  remain. 

The  gummy  growth  in  its  site  can  be  limited  to  the  derm; 
oftener  it  arises  from  the  periosteum,  and  implicates  the  wall  of 
the  skull.  In  each  situation  it  may,  under  proper  local  and  con- 
stitutional treatment,  disappear  by  absorption,  and  leave  only 
slight  marks  of  its  previous  existence:  viz.,  such  fortunate  ending 
is  often  obtained  by  the  topical  use  of  iodine,  and  the  internal 
administration  of  mercury  and  iodine.  In  many  cases,  however, 
the  gummy  growth  ends  by  caseous  and  sup|>urative  change;  and 
then,  if  the  soft  parts  are  the  site,  they  become  the  site  of  chronic 
ulceration,  of  which  the  healing  is  tedious.  But  in  those  cases 
in  which  the  gummata  arise  from  the  periosteum,  or  still  deeper 
from  the  diploetic  structure  of  the  frontal  bone,  then  extensive 
caries  may  be  the  event,  in  which  the  outer  plate,  or  the  entire 
thickness  of  the  wall,  may  be  destroyed.  When  the  gummata 
occupy  large  districts  of  the  bone,  these  growths  in  their  regressive 
change  may,  by  depriving  the  osseous  tissue  of  its  nutrition, 
cause  death  of  separate  sections;  or  a  large  mass  of  the  vertical 
portion  of  the  os  frontis  may  become  necrosed.  Caries  or  death 
of  small  sections  of  the  osseous  structure  is  oftenest  seen  in  the 
supra-orbital  ridges;  the  txternal  portion  of  those  ridges  is  a 
frequent  site  of  syphilitic  caries.  Whether  the  necrosis  be  on  a 
large  or  a  small  scale,  the  dead  structure  must  be  removed;  also 
the  affected  bone  bordering  the  necrosed  portion  must  be  excised. 
This  rule  is  specially  incumbent  when  the  caries  is  in  the  form 
of  a  fistula,  in  w^hich  form  it  often  penetrates  the  entire  wall.  If 
such  fistula  be  merely  curetted,  it  will  not  close,  but  caries  will 
soon  reappear  in  the  sides  around.  Where  large  portions  of  bone 
are  necrosed,  they  should  be  removed  through  incisions  made  in 
the  soft  parts;  and,  at  the  same  time,  marginal  portions  which 
are  diseased  should  be  excised.  And  the  operator  should  ever 
bear  in  mind  that  this  local  excision  is  but  plucking  leaves  from 
the  tree,  which  also  must  be  attacked  by  collateral  constitutional 
treatment,  plied  rapidly,  persistently  and  thoughtfully. 

Frontal  Sinus. — The  frontal  bone  is  the  site  of  two  hollow 
spaces,  which  are  situated  above  the  root  of  the  nose,  and  each  one 


FRONTAL    SIXUS.  319 

lies  respectively  over  the  inner  portion  of  the  orbit.  Similar  to 
a  monstrous  diploetic  cell,  they  are  situated  between  the  inner 
and  outer  plates  of  the  cranial  wall.  These  spaces,  filled  with  air, 
communicate  b}^  means  of  an  infundibuliform  opening  with  the 
middle  nasal  meatus.  They  are  absent  in  childhood,  and  only 
begin  to  appear  when  the  subject  is  over  ten  years  of  age,  and  at 
eighteen  years  these  cavities  have  nearly  reached  full  develop- 
ment. Their  appearance  is,  in  some  measure,  coincident  with 
puberty;  yet  in  a  few  subjects  they  never  develop,  and  when 
present,  they  vary  much  as  to  dimension,  being,  in  some  cases, 
very  diminutive.  If  a  section  be  made  of  a  skull,  in  which  the 
sinuses  are  of  normal  dimensions,  the  space  will  be  found  to  be 
pyramidal,  the  base  resting  on  the  partition  which  sej^arates  the 
two,  and  the  apex  lying  over  the  external  orbital  j^rocess.  One 
is  usuall}''  larger  than  the  other,  and  the  separating  portion  does 
not  lie  in  the  median  line.  Each  sinus  will  contain,  on  an  aver- 
age, a  half  drachm  of  water.  They  are  lined  by  a  mucous  mem- 
brane, which  is  white,  smooth,  thin  and  non-vascular,  thus  differ- 
ing from  the  mucous  membrane  which  lines  the  nasal  passages, 
which  is  much  tlncker,  very  vascular,  and  studded  with  glands, 
which  do  not  exist  in  the  lining  of  the  sinus.  This  mucous 
membrane  has  a  ciliated  epithelium,  is  provided  with  nervous 
filaments,  and  its  deeper  stratum  readily  ossifies. 

This  larger  air  cavity  is  tlie  subject  of  accidental  injury  and 
disease.  Fracture  has  here  occurred;  likewise,  gunshot  wound. 
In  case  of  fracture,  the  outer  plate  alone  may  be  broken,  and 
forced  into  the  sinus,  either  as  depressed  bone,  with  attachment  of 
the  fragment  to  the  bone  adjacent,  or  the  fragment  maybe  quite 
detached  and  lie  loose  in  the  hollow  space.  And,  lastly,  from  some 
penetrating  object,  as  a  piece  of  broken  glass  pottery,  or  a  pointed 
object,  both  walls  may  be  broken.  The  error  has  been  made 
of  mistaking  fracture  of  the  outer  wall,  accompanied  by  depres- 
sion, for  fracture  which  implicated  both  outer  and  inner  plates; 
for  in  the  former,  similar  to  what  is  seen  in  the  latter,  blood, 
tissue  or  pus  may  rise  and  sink  in  the  cavity,  and  such  motion  may 
be  wrongly  referred  to  encephalic  movement,  while  it  is  merely 
caused  by  the  action  of  the  air  in  the  nasal  passages.  A  French 
surgeon  records  such  a  mistake  made  in  the  diagnosis  of  an 
injury  made  in  this  region.  If  the  probe  failed  to  determine  the 
extent  of  the  injury,  light  on  its  nature  might  be  gotten  by  letting 
the  patient  breathe  through  his  nose,  or  suspend  the  breath  for  a 
few  seconds;  in  either  act  the  fluid  lodged  in  the  sinus  would 
remain  quiescent. 


320  SURGERY    OF    THE    FRONTAL    REGION. 

A  simple  fracture  with  only  depression  of  the  bone,  without 
opening  throu<;li  the  skin,  if  not  a  signal  deformity,  sliould  be  left 
to  the  care  of  nature;  should,  liowever,  the  deformity  be  striking, 
by  drilling  a  small  opening,  the  bone  might  be  restored  to  its  natural 
place.  If,  with  an  open  wound;  the  bone  has  been  broken  and  a 
fragment  lies  loose  in  the  sinus,  this  must  be  removed,  through 
the  existing  opening  if  this  is  possible,  or  if  this  be  too  small, 
enlarge  it.  In  such  injury,  unusual  care  should  be  given  to  secure 
occlusion  by  means  of  aseptic  dressing,  lest  exposure  of  the 
fractured  bone  should  permit  the  broken  margins  to  die,  and  thus 
a  tedious  healing  result. 

The  frontal  sinus  has  been  opened  by  gunshot  injury,  and  the 
missile  has  lodged  and  remained  for  a  long  time  in  the  cavity, 
and  if  the  missile  were  so  impacted  as  to  be  motionless,  it  might 
be  left  there;  the  anxiety  of  the  patient  would  seldom  be  content 
with  such  inert  conservatism.  The  ball  could  be  removed  by 
an  opening  made  with  the  trephine.  The  missile,  in  a  reported 
case,  escaped  through  the  nose. 

Larvse  of  insects,  in  botii  man  and  animals,  have  entered  the 
sinuses  from  the  nose,  and  have  developed  there.  Di.slodgment 
of  such  intruders  has  been  effected  by  arsenical  vapors;  it  is 
probable  that  the  fumes  of  tobacco  would  be  an  equally  efficient 
as  well  as  a  much  safer  agent  to  be  used,  and  to  many  patients  it 
would  not  be  repulsive. 

Blumenbach  mentions  a  case  of  a  curious  intruder  into  the 
frontal  sinus,  viz.,  a  many  footed  insect  named  scolopendra  elec- 
trica,  which,  safely  housed,  tortured  its  bearer  for  over  a  year. 
Osteoma  originating  in  the  frontal  sinus  was  the  matter  of 
research  by  Dolbeau,  in  1871.  He  says  that  the  osseous  growth 
proceeds  from  the  mucous  lining,  and,  hence,  that  it  is  easily 
removed  when  the  front  wall  of  the  sinus  is  opened;  in  fact,  that 
such  osteoma  can  be  lifted  from  the  cavity  of  the  sinus  as  readily 
as  a  stone  can  be  removed  from  the  bladder  to  which  an  opening 
has  been  incised.  Richet  asserts  that  the  removal  is  more  diffi- 
cult; he  cites  cases  in  which  it  was  necessary  to  chisel  the  growth 
from  the  bony  wall  of  the  sinus. 

The  lining  of  the  sinuses  is  the  site  of  an  excretion  which,  from 
morbid  change  of  the  generating  membrane,  may  become  muco- 
purulent. As  long  as  the  outlet  into  the  middle  nasal  meatus 
remains  open,  this  material  would  have  free  outlet;  but  should 
the  funnel-shaped  orifice  become  occluded,  then  this  content 
would  be   retained,  and  induce  disease  in  the  containing  wall; 


FRONTAL    SINUS.  321 

and,  if  unrelieved,  the  continued  increase  of  the  muco-pus,  by 
pressure,  would  reopen  the  normal  outlet,  or  pierce  the  front  wall 
of  the  sinus.  The  pent-up  material,  from  the  author's  observa- 
tion, singularly  and  fortunately  enough,  spares  the  posterior  thin 
wall,  and  causes  caries  of  some  point  in  the  anterior  wall,  which 
finally  opens  and  allows  the  content  to  escape. 

Before  the  appearance  of  pus  through  the  nose  or  the  anterior 
wall  of  the  sinus,  it  would  be  difficult  to  determine  its  presence 
there,  and  the  only  trustworthy  means  of  doing  so  would  be  to 
make  an  opening  into  the  cavity;  and  this  could  be  done  through 
the  nose,  or,  more  directly,  by  drilling  a  small  opening  through 
the  anterior  wall;  the  latter  would  be  the  preferable  way,  since 
afterwards  through  such  opening  a  flexible  probe  or  silver  wire 
could  be  introduced  and  carried  to  the  lower  angle  of  the  sinus, 
and  the  occluded  outlet  opened.  And  even  a  drainage  tube 
might  be  carried  from  the  sinus  into  the  nose,  and  be  tied  and 
retained  in  place  for  what  time  would  be  requisite  for  the  recov- 
ery of  the  cavity.  To  hold  the  tube  in  place,  a  thread  should  be 
fixed  to  its  U23per  end,  and  at  its  point  of  attachment  so  enlarged 
by  a  knot  as  to  i^revent  the  tube  from  escaping  unless  considera- 
ble traction  be  made  on  it.  This  thread  will  lie  alongside  of  the 
tube  in  the  middle  nasal  meatus.  Through  this  tube  the  sinus 
can  daily  be  washed  out  with  some  antiseptic  fluid;  meantime, 
any  fluid  excreted  there  can  readil}?-  escape.  And  when  the 
escaping  material  denotes  a  return  to  health,  the  tube  can  be 
withdrawn  by  making  traction  on  it  and  the  thread  at  the  same 
time.  It  is  probable  that  the  tube  would  have  to  be  retained  in 
place  for  three  months  at  least,  before  the  sinus  would  be  restored 
to  healthy  condition. 

When,  however,  the  case  comes  into  the  surgeon's  hands  after 
the  sinus  has  opened  entirely,  and  there  is  a  fistulous  opening 
where  muco-pus  opened,  then  another  course  of  treatment  will 
be  demanded.  In  such  a  patient,  the  anterior  wall  of  the  sinus 
will  be  found  in  a  carious  or  semi-necrosed  state:  a  condition 
most  unfavorable  to  healing.  Five  cases  of  the  kind  have  been 
seen  and  treated  by  the  writer:  the  sinus  had  an  opening  piercing 
the  anterior  wall.  In  one  of  the  cases,  the  orifice  was  beneath  the 
superciliary  arch,  where  the  orbital  plate  ends  in  the  vertical 
portion  of  the  os  frontis;  in  three  others,  the  opening  was 
slightly  higher  than  the  point  here  mentioned;  and  in  a  fifth 
one,  the  orifice  into  the  sinus  was  near  the  middle  point  of  the 
anterior  wall  of  the  sinus.     In  the  patients  here  mentioned,  who 


322  SURGERY  OF  THE  FRONTAL  REGION, 

were  all  adult  men,  the  following  were  the  causal  agencies:  ir. 
one,  the  affection  of  the  sinus  was  the  sequel  of  measles,  con- 
tracted after  puberty;  in  one  it  was  from  constitutional  syphilis; 
in  a  third,  the  cause  was  traumatic,  in  which  the  bone  had  been 
fractured  with  an  open  wound  of  the  soft  parts:  in  a  fourth  it 
was  traceable  to  scrofula,  and  in  a  fifth  man  it  was  doubtful 
whether  it  had  syphilitic  or  scrofulous  paternity. 

In  the  four  cases  which  originated  in  constitutional  disease, 
deep-seated  pain  of  a  neuralgic  character  had  preceded  the  open- 
ing of  the  sinus  for  a  long  period. 

In  the  patient,  in  whom  the  sinus  was  opened  by  fracture  due 
to  violence,  there  was  a  persistent  trial  of  various  means  to  effect 
a  cure:  injections  of  iodine  and  other  stimulating  agents  were 
used  topically  with  the  object  of  restoring  the  inner  wall  to  a 
sound  condition.  In  this  way  the  discharge  was  temjjoraril}' 
arrested;  yet  this  soon  reappeared.  Curetting  the  cavity  was 
also  ineffective.  The  man  retained  his  diseased  sinus  for  over  a 
year,  when  he  died  from  a  chronic  diarrhoea,  which  seemed  to 
have  no  connection  with  his  local  trouble.  A  necropsy  was 
made,  from  which  it  was  apparent  that  the  local  treatment  which 
had  been  pursued,  had  fallen  far  short  of  restoring  the  diseased 
wall  to  integrity.  In  fact,  when  the  anatomical  conditions  pres- 
ent are  considered,  it  is  seen  that  they  are  wholly  unsuited  to 
effecting  a  cure:  the  breach  in  the  wall  cannot  bridge  over  with 
osseous  structure.  And  even  if  such  closure  were  possible  by 
dermal  covering,  and  though  the  usual  outlet  of  the  sinus  were 
reopened,  it  is  probable  that  the  latter  would  become  occluded 
again,  and  tlie  pent-up  excreta  would  force  a  passage  through 
the  point  which  had  been  closed.  These  facts,  and  the  failure  to 
accomplish  anything  satisfactory  by  conservative  topical  treat- 
ment, convinced  the  writer  that  the  proper  way  to  treat  such 
cases  is  excision  of  the  anterior  wall  and  total  obliteration  of  the 
sinus.  In  this  way  four  cases  have  been  treated  with  successful 
result  by  the  writer.  To  perform  this  osseous  exsection,  the  soft 
parts  covering  the  anterior  wall  should  be  carefully  uplifted  by 
means  of  a  long-horizontal  and  a  short-vertical  incision ;  tlie  verti- 
cal cut  should  end  over  the  inner  angle  of  the  eye.  Next,  by 
means  of  a  pair  of  forceps,  which  is  used  by  the  dentist  for  alveolar 
excision,  the  removal  is  done  by  inserting  one  blade  of  tlie  forceps 
into  the  cavity,  and  excising  a  portion  of  the  border  of  the  outer 
wall.  This  work  of  excision  by  piecemeal  can  l)e  continued  in 
all  directions,  until  the  whole  of  the  necrosing  wall  is  removed. 


TREPHINING    OVER    THE    FRONTAL    SINUS.  323 

As  remarked  before,  the  inner  wall  of  the  frontal  sinus  is  found 
but  slightly  affected  in  these  cases;  and  whatever  abnormal 
structure  is  discovered  there,  can  be  scraped  off  with  a  curette. 
The  wound  is  now  to  be  sprinkled  with  iodoform,  closed  by  suture, 
with  provision  made  for  temporary  drainage;  this  latter  can  be 
removed  in  the  fourth  day.  There  will  be  recovery  in  from  three 
to  four  weeks.  This  speedy  healing  is  in  marked  contrast  with 
the  long  and  tiresome  efforts  which  are  often  made  in  such  dis- 
ease to  obtain  a  cure  by  conservative  means,  which  end  in  failure. 
In  the  case  which  had  arisen  from  an  exanthematous  affection, 
the  writer  ran  through  the  list  of  topical  means,  including  curet- 
ting, with  the  only  result  to  see  the  suppurative  action  soon 
reappear.  After  tliis  radical  excision  (the  first  case  in  which 
it  was  tried)  both  patient  and  operator  were  surprised  to  see  the 
part  entirely  healed  at  the  end  of  twenty  days. 

The  question  is  asked:  Does  this  exsection  not  leave  a  formida- 
ble scar  and  change  of  form?  This,  in  fact,  is  a  serious  objection 
to  the  procedure ;  a  permanent  cicatrix  with  depression  of  surface 
remains.  But  the  patient  is  cured;  he  is  freed  from  the  pus- 
exuding  orifice  which  hitherto  disfigured  his  forehead;  and  he  is 
delivered  from  the  necessity  of  spending  some  time  daily  in 
cleansing  this  diseased  point.  Before  the  operation  is  done,  how- 
ever, the  patient  should  have  these  points  placed  clearly  before 
him,  and  as  he  elects,  so  should  the  surgeon  proceed.  In  all 
operations  which  are  done  for  cosmetic  purposes,  and  which  do 
not  concern  the  life,  but  the  convenience  of  the  patient,  the  option 
of  the  latter,  unbiased  by  persuasion,  should  guide  the  operator; 
the  latter  should  scrupulously  withhold  his  hand  from  giving 
that  artful  touch  to  the  scales,  which,  too  often  unperceived,  turns 
them  from  impartial  poise.  In  all  such  cases,  an  excellent  rule 
is  to  let  "even-handed  justice  present  the  chalice"  to  the  operator; 
and  if  he  would  willingly  accept  it,  the  patient  will  not  err  in 
commending  it  to  his  own  lips. 

Trephining,  how  done  over  the  Frontal  Sinus. — As  site  for  enter- 
ing the  cranial  cavity  the  region  of  the  frontal  sinus  is  never 
chosen;  sometimes,  however,  it  becomes  necessary  to  trephine 
there,  and  then  the  operation  requires  some  modification.  If  the 
same  instrument  be  continued  through  the  outer  and  the  inner 
plates,  when  the  boring  crown  reaches  the  inner  plate,  it  will 
become  entangled  with  the  mucous  lining  of  that  plate,  and  uplift 
and  tear  this  structure  in  an  irregular  manner.  To  avoid  this, 
Boyer  advises  to  use  a  larger  crown  to  perforate  the  outer  plate 
and  a  smaller  one  to  cpen  the  inner  one. 


324  SURGERY    OF    THE    FKOXTAl.    REGION. 

Schillbach,  of  Jena,  in  ISGO,  advised  to  trephine  through  the 
outer  j>late,  as  liad  previously  been  done  by  Reid,  for  the  removal 
of  neoplasms  which  arise  in  the  sinus,  or  which,  originating  in  the 
nose,  extend  into  the  frontal  sinus;  and  such  operation  maybe 
required  for  the  removal  of  a  foreign  body  that  has  lodged  there. 
In  such  cases,  Schillbach  counsels  to  expose  the  bone  by  a  hori- 
zontal and  vertical  cut  over  the  inner  angle  of  the  eye.  The 
opening  is  to  be  made  at  the  junction  of  the  nasal  bone  with  the 
frontal  bone.  If  need  be,  some  bone  may  be  exsected.  In  three 
cases,  trephining  was  done  in  this  way.  After  the  trephining  has 
accomplished  its  purpose,  the  communication  witli  the  nose 
should  be  established,  and  the  opened  integument  closed  hy 
suture. 


CHAPTER  IX. 


NOSE    AND    NASAL    PASSAGES. 


The  nose,  as  the  portal  through  which  objects  of  smell  are 
admitted,  and  by  which  in  respiration  air  should  enter,  has  recently 
been  abandoned  to  the  specialist;  still  many  of  its  affections  fall 
within  the  sphere  of  general  surgery;  and  prior  to  studying  these 
affections,  it  is  proper  to  consider  some  points  in  the  anatomical 
structure  of  the  nasal  apparatus. 

In  its  central  and  promontory-like  position  the  nose  is  favor- 
ably situated  to  receive  violence,  and  avert  in  some  degree  its 
effects  from  the  eyes  and  front  of  the  cranium.  The  visible 
prominent  portion  is  composed  anteriorly  of  cartilage,  and  pos- 
teriorly of  bone;  a  disposition  likewise  protective  in  nature.  The 
prominent  external  portion  presents  a  root,  dorsum,  tip  or  lobule, 
sides,  wings,  septum,  and  openings  of  the  nostrils.  And  each  of 
these  may  vary  in  outline,  figure  or  volume  ;  such  variety  being 
characteristic  of  race.  And  each  of  these  parts  of  the  nose  may, 
through  injury  or  disease,  deviate  so  much  from  normal  type  as 
to  become  the  subject  of  surgical  treatment. 

The  dermal  integument  at  the  root  of  the  nose  is  thin,  smooth 
and  easily  moved  on  the  subjacent  bone;  but  below,  where  it  lies 
on  the  cartilage,  it  is  closely  adherent  to  the  latter,  and  is  thick: 
hence,  the  integument  at  the  root  of  the  nose  is  suited  for  plastic 
purposes,  since  it  admits  of  displacement;  while  that  covering 
the  cartilaginous  portion  is  ill  suited  for  such  purposes.  The  skin 
of  the  nose  has  a  rich  vascular  endowment;  this  condition  adds 
to  its  vitality  and  favors  the  rapid  healing  of  wounds  here :  even 
if  a  portion  be  partially  or  wholly  detached.  This  vascular 
quality  favors  hypertrophy.  The  skin  of  the  nose  is  the  site  of 
sebaceous  glands,  of  which  the  distribution  is  irregular:  viz.,  few 
glands  exist  on  the  dorsum,  while  they  are  more  numerous  on 
the  sides,  and  most  abundant  on  the  wings  of  the  nose :  hence, 
the  more  frequent  derangement,  or  disease,  of  the  glands  in  the 
latter  sites.     The  subcutaneous  tissue  is  thin  and  loose  over  the 

( 325 ) 


32G  .  SOHE    AND    NASAL    PASSAGES. 

nasal  bones;  but  on  the  cartilages  it  is  thick  and  closely  adherent 
to  the  skin. 

The  muscles  of  the  nose,  greater  in  name  than  in  material, 
puzzle  the  anatomist  to  clearly  demonstrate  them,  since  they  are 
dwarfed  to  inconspicuous  vestiges,  except  the  pyramidalis  no.se, 
whicii,  reaching  from  the  root  of  the  nose  upwards,  is  concerned 
in  rhinoplasty,  when  restoring  material  is  taken  from  the  frontal 
region.  If  this  muscle  be  included  in  the  twisted  flap,  the  hitter 
is  lessened  by  contraction  of  the  muscular  element. 

Tiie  osteo-cartilaginous  framework  maintains  the  nose  in  its 
prominent  form;  and  from  disease  or  injury  of  it,  sunken  nose 
can  result.  The  osseous  portion  consists  of  the  nasal  bones,  and 
a  partition  composed  of  the  vomer  and  the  perpendicular  plate  of 
the  ethmoid.  The  nasal  bones,  arch-like,  have  great  strength, 
enabling  them  to  resist  external  violence;  but  the  partition,  whicli 
is  less  strong,  is  screened  from  injury  by  the  protective  vault 
above;  in  fact,  it  adds  to  the  strength  of  the  latter.  The  carti- 
laginous portion  is  movable,  and,  according  to  the  statement  of 
anatomists,  cannot  be  broken,  though  surgeons  have  reported 
such  fracture. 

The  external  skin  passes  into  the  nares,  and  as  it  penetrates 
inwards,  attiie  entrance  it  contains  strong,  sliort  hairs;  but  as  it 
reaches  farther  inwards,  it  loses  its  dermal  character,  and  assumes 
the  character  of  mucous  membrane:  yet,  as  mucous  membrane, 
a  portion  of  it  is  imperfect  in  excretory  function;  but  tliis  is 
compensated  by  fluid  which  is  poured  into  the  nasal  passages  on 
every  side  from  the  adjacent  sinuses,  viz.,  maxillary,  sphenoidal 
and  frontal. 

]Mucli  of  the  surface  of  the  nasal  fossie  is  lined  by  a  mucous 
membrane  of  a  peculiar  character,  named  the  pituitary  or  Schnei 
derian  membrane.  The  Schneiderian  membrane  is  thicker  than 
ordinary  jnucous  membrane;  this  thickness  is  such  that  itlessen.s 
the  space  of  the  fossie,  and  tends  to  lessen  the  calibre  of  the 
orifices  which  open  into  the  cavity.  It  is  thick  and  resistant 
where  it  lines  the  floor  of  the  nares,  as  well  as  where  it  invests  the 
basilar  process  of  tlie  occipital  bone;  but  on  the  turbinated  bones 
it  is  soft  and  .pulpy.  This  membrane  is  composed  of  two  layers: 
a  deep  one  that  adheres  to  the  bones  and  cartilages,  and  is  fibrous 
in  structure  ;  and  a  superficial  one  which  lies  on  the  jDreceding  is 
soft  and  very  vascular;  and  above,  where  the  olfactive  nerve  enters, 
this  superficial  stratum  is  clad  by  ciliated  epithelium.  Mucous 
glands  lie  in  the  pituitary  membrane. 


DEFECTS.  327 

The  nasal  cavity  is  divided  into  a  right  and  left  passage  by 
the  vertical  partition ;  and  these  passages  are  bounded  by  an 
internal,  external,  superior  and  inferior  wall.  The  inner  wall, 
usually  regular,  may  be  irregular  from  deflection  or  deviation  of 
the  vertical  septum;  the  outer  wall  is  in  the  highest  degree  irregu- 
lar in  surface,  owing  to  the  scroll-like  form  of  the  turbinated 
bones  which  are  attached  to  it  and  constitute  a  part  of  the  wall. 
The  upper  wall  is  narrow,  and,  according  to  Richet,  it  measures 
from  one  inch  and  three-quarters  to  two  inches  in  length.  The 
lower  wall,  or  floor,  measured  from  the  anterior  nasal  spine  to  the 
posterior  one,  is  shorter  than  the  upper  one. 

Behind  the  nasal  passage  lies  a  space,  which,  as  the  frequent 
site  of  neoplasm,  should  be  studied  by  the  surgeon.  Though  it 
may  be  represented  as  having  six  sides,  yet  two  of  these  are  open, 
viz.,  the  anterior,  which  opens  into  the  posterior  nares,  and  the 
inferior  one,  which  is  only  closed  when  the  soft  palatal  veil  is 
uplifted,  as  occurs  in  swallowing.  The  other  four  sides,  which 
are  bounded  by  walls,  are  the  superior,  posterior  and  lateral. 
The  superior  wall,  bounded  by  the  occipital  basilar  process,  forms, 
with  the  posterior  wall,  an  angle  of  one  hundred  and  thirty 
degrees;  and  if  the  head  be  turned  backwards,  the  angle  becomes 
greater,  so  that  the  two  surfaces  are  nearly  continuous.  This  dis- 
position is  utilized  when  it  is  necessary  to  pass  a  tube  or  sound 
through  the  nostrils  into  the  pharynx;  such  instrument  passes 
without  interruption.  The  posterior  wall  corresponds  to  the  atlas 
and  axis;  it  is  two-thirds  of  an  inch  high.  The  lateral  walls  are 
adjacent  to  the  carotid  artery,  the  internal  jugular  vein,  the  vagus, 
hypoglossal  and  the  sympathetic  nerves.  On  this  wall  opens  the 
Eustachian  tube,  at  a  point  on  a  level  with  the  prolongation  of 
the  inferior  turbinated  bone. 

The  nasal  fossae  are  divided,  on  each  side,  into  three  passages 
by  the  turbinated  bones;  these  passages  are  known  as  the  superior, 
middle  and  inferior  meatuses.  The  middle  meatus,  into  which 
open  the  outlets  from  the  frontal  and  maxillary  sinuses,  and  the 
lower  meatus,  into  which  the  lachrymal  canal  ends,  are  the  two 
passages  with  which  the  surgeon  is  mainly  concerned. 

Defects. — The  nose  is  the  site  of  defect,  which  may  be  congeni- 
tal or  acquired;  it  may  also  be  the  site  of  injury  and  disease. 

As  congenital  defect,  a  case  of  absence  of  the  nose  has  been 
seen  by  Maisonneuve :  instead  of  a  nose  there  only  existed  a  plane 
surface  pierced  by  two  openings.  This  is  the  only  instance  of 
such  defect  that  the  writer  finds  on  record.     An  attempt  was 


328  XOSK    AND    NASAL    l'ASSA(iKS. 

made  by  Maisoimeuve  to  improve  the  appearance  of  the  part  by 
hfting  up  a  bridgc-Hke  fold  of  skin,  provided  with  a  median  nar- 
row portion,  whicli  being  turned  inwards,  served  as  a  septum  or 
division  of  the  subjacent  space.  As  there  was  no  cartilage  to 
maintain  the  form,  it  is  probable  that,  like  many  examples  of 
restoration  of  parts  by  the  plastic  surgeon,  the  restored  i)art  is 
fairer  in  description  than  in  actuality. 

Asthereverse  of  thedefect  mentioned, cases  have  been  observed 
in  which  nature  was  too  generous  in  her  gifts  to  the  new-born: 
the  infant  appeared  with  a  double  nose.  Also,  the  new-born  has 
had  a  nose  whicli  was  much  too  great  in  volume.  Duplicate  form 
would  puzzle,  if  not  baffle,  surgical  effort;  more,  however,  could 
be  done  where  there  was  merely  excess  of  volume;  yet  even  here 
there  should  not  be  haste  to  intervene.  For  the  infant's  nose, 
which  is  always  shapeless  at  birth,  through  the  plastic  molding 
of  evolution  undergoes  singular  changes,  changes  by  which  feature 
is  acquired  which  is  absent  in  the  new-born;  for  at  birth  infantile 
noses  are  all  alike:  featureless,  expressionless;  feature,  expres- 
sion, and  character,  if  an  old  writer,*  be  credited,  appearing  in 
the  changes  which  growth  brings.  Hence,  in  view  of  the  im- 
provement in  form  which  time  may  bring  to  the  abnormally 
large  nose  of  the  infant,  intervention  should  not  be  premature, 
lest  nature  be  thwarted  in  her  reparative  effort.  Should,  how- 
ever, the  infantile  nose  have  such  excessive  proportions  that 
time  instead  of  retrenching  will  add  to  them,  then  some  of  the 
excess  may  be  removed  by  cuneiform  excisions  so  situated  and 
directed  that  when  closed  by  sutures,  the  remaining  part  will 
conform  to  normal  form. 

The  entrance  of  the  nostrils  of  tlje  new-born  may  be  abnor- 
mally narrow;  such  narrowness,  for  its  relief,  does  not  demand 
operative  interference;  care  is  chiefly  to  bo  directed  to  })reventing 
the  nose  from  becoming  still  narrower,  as  occurs  where  there  is 
ulcerative  disease.  To  oppose  closure,  tamponing  plugs  should  be 
introduced  from  time  to  time. 

Injury. — The  nose  may  be  the  site  of  incised,  lacerated,  and 
contused  wounds,  with  or  without  fracture,  and  there  may  be 
fracture  without  lesion  of  the  investing  integument. 

The  incised  wound  occurring  from  accident,  or  intentionally 
made  by  the  surgeon's  knife,  is  not  infrequent.  Such  wound, 
owing  to  the  vascularit}'  of  the  derm  here,  bleeds  freely;  and  for 

"^Xoscitur  ex  nam. 


FRACTURE    OF    THE    NASAL    BONES.  329 

the  same  reason,  heals  readily.  This  is  true  of  both  incised  and 
contused  wounds.  And  even  where  a  portion  of  the  nose  has 
been  cut  off,  the  detached  part  can  often  be  reunited.  Beranger- 
Ferraud  has  made  research  in  this  field,  and  finds  sixty-five  cases 
on  record  in  which  the  detached  portion  of  the  nose  was  success- 
fully restored  to  its  place.  Martin  and  Hoffacker  have  collected 
a  number  of  similar  cases.  According  to  Galen,  even  though  the 
fragment  has  been  separated  from  the  remainder  of  the  nose  for 
from  twenty  to  sixty  hours,  yet  an  attempt  should  be  made  to 
save  it,  since  recovery  has  been  obtained  in  such  cases.  In 
attempting  reunion  of  such  fragment,  the  clots  of  blood  should 
be  carefully  washed  from  it,  as  well  as  from  the  surface  to  which 
the  former  is  to  be  restored.  The  bleeding  must  be  thoroughly 
staunched,  even  though  it  be  necessary  to  tie  a  vessel.  The  raw 
surface  being  thoroughly  cleansed  with  alcoholized  or  sublimated 
water,  the  fragment  must  be  fixed  securely  in  position  by  means 
of  metallic  suture,  or  by  the  twisted  suture.  Warm,  moist  dress- 
ing should  be  applied  over  the  part.  Cold  dressings,  used  by  some, 
are  improper,  since  the  cold  must  contract  the  parts  and  impede 
the  cell-growth  requisite  for  healing.  The  replaced  fragment 
often  remains  cold  and  pale  for  some  time;  in  fact,  for  hours  it 
may  have  a  cadaveric  hue.  Holmes  Coote  observed  an  alterna- 
tion from  paleness  to  redness,  and  from  redness  to  paleness,  and 
these  changes  of  color  continued  for  two  or  three  days.  These 
facts  encourage  the  surgeon  to  j^ersevere  in  his  endeavors  to  save 
the  detached  part,  in  such  wounds  of  the  nose,  and  not  to  aban- 
don his  efforts  until  the  fragment  is  surely  dead. 

Fracture  of  the  Nasal  Bones. — The  external  osseous  fabric  of 
the  nose,  though  having  great  power  of  resistance,  is  not  unfre- 
quently  fractured,  Hippocrates  deemed  this  injury  sufficiently 
important  to  devote  several  chapters  to  it.  Celsus,  likewise, 
wrote  a  chapter  on  the  same  subject.  These  writers  also  describe 
fracture  of  the  nasal  cartilages,  which  is  denied  by  modern 
surgeons.  The  classification  of  Celsus  is  fracture  of  parts  in 
front,  and  lateral  fracture.  A  brief  classification,  in  which  the 
principal  attendant  conditions  are  included,  is  that  of  lateral 
fracture,  which  may  be  unilateral  or  bilateral ;  subcutaneous  or 
open;  and  fracture  with  or  without  displacement  of  the  broken 
bone. 

Fracture  of  the  nasal  bones  is  from  violence,  of  which  the 
impact  may  be  directly  in  front,  or  on  one  or  both  sides;  thus  one 
or  both  nasal  bones  can  be  broken.  The  adjacent  nasal  process 
22 


330  NOSE   AND   NASAL   PASSAGES. 

of  tlie  superior  maxillary  bone,  in  severe  fracture,  may  also  be 
broken  without  a  wound  in  the  soft  parts,  or  tliere  niny  be  a 
breach  in  the  mucous  membrane,  or  derm,  or  in  both.  As  a  rule, 
the  external  surface  is  not  wounded;  the  inner  or  mucous  lining- 
is  commonly  injured,  and,  as  a  result,  there  is  bleeding.  This 
luiemorrhage  is  ordinarily  small  in  amount;  yet  a  case  is  recorded 
in  which  the  patient  bled  to  death  from  nasal  fracture. 

In  fracture  limited  to  one  side  of  the  nose,  tlie  broken  nasal 
bone  is  usually  depressed.  Or  if  botii  bones  be  fractured  by  vio- 
lence received  directly  in  front,  the  dorsum  is  driven  backwards, 
and  the  nose  is  flattened  or  sunken.  Again,  wiiere  the  violence 
has  been  received  on  one  side,  the  nose  may  be  deflected  or  driven 
wholly  to  one  side,  and  it  will  then  be  inclined  towards  one  cheek. 
In  any  of  tliese  cases,  the  change  of  position  and  alteration  of 
form  would  clearly  indicate  the  nature  of  the  injury;  the  surgeon's 
eye,  rather  than  his  touch,  would  make  the  diagnosis,  for  crepitus, 
which  is  present  in  fracture  of  bones  elsewhere,  can  scarcely  be 
detected  in  this  injury.  The  injury  is  not  always  limited  to  the 
nose,  for  if  the  violence  is  not  exhausted  in  the  fracture  of  the 
nasal  bones,  it  will  pass  to  the  ethmoid  bone  and  do  further  vio- 
lence by  either  fracturing  this  bone,  as  once  claimed,  or  it  will 
cause  concussion  of  the  brain.  Hyrtl  has  experimented  on  the 
cadaver  by  striking  and  breaking  the  nasal  bones,  and  yet  in  no 
case  did  he  find  that  the  ethmoid  bone  had  been  broken;  the 
cribriform  plate  of  that  bone  is  so  strong,  he  thinks,  that  it  can 
resist  fracture  in  such  cases,  and,  hence,  in  most  if  not  in  all  cases, 
the  cerebral  injury  present  is  due  to  concussion. 

Treatment. — The  treatment  consists  of  two  acts:  the  restoration 
of  the  broken  bone  to  natural  site,  and  the  maintenance  of  this 
position  by  proper  dressing. 

To  restore  to  normal  position  the  broken,  deviated  and 
depressed  nasal  bone,  or  bones,  a  finger,  or  something  similar  to 
it,  must  be  passed  into  the  nose  beneath  the  displaced  bone,  when 
the  latter  is  to  be  lifted  and  restored  to  its  place.  As  the  surgeon's 
finger  is  commonly  too  large  to  enter  the  nostril,  hence  some 
smaller  instrument  must  be  used,  and  for  this  purpose  the  grooved 
sound,  which  always  should  have  a  place  in  the  pocket  case,  may 
be  used.  The  round  end  of  the  male  or  female  catheter  can  be 
used  for  the  same  i>urpose.  Whatever  is  employed  must  have  a 
smooth  surface  that  will  not  wound  the  mucous  membrane. 
"With  the  instrument  which  is  used  to  restore  the  fragments  to 
site,  the  surgeon's  fingers  inust  carefully  cooperate,  and  the  work 


FRACTURE  OF  THE  XASAL  BOXES.  331 

of  uplifting  and  molding  be  continued  until  the  nose  regains  its 
natural  figure.  When  the  fracture  is  bilateral,  which  is  usually 
the  case,  then  the  modeling  must  be  done  in  each  nostril;  and,  if 
the  nasalbones  be  not  displaced  directly  backwards,  one  bone  is  usu- 
ally depressed  and  the  other  uplifted;  in  such  state  the  modeling 
consists  in  pressing  one  side  inwards,  and  uplifting  the  other. 
And  as  there  is  concurrent  deviation  of  the  septum,  this  is  likewise 
to  be  restored  to  vertical  position.  If  this  lateral  deflection  be 
overlooked,  the  calibre  of  the  nostrils  would  be  altered:  a  condition 
which  might  interfere  with  normal  respiration  and  olfaction; 
especially  with  the  latter,  since,  for  the-  accomplishment  of  smell- 
ing, it  seems  necessary  that  the  current  of  inspired  air  should  be 
compressed.  Hence,  in  the  endeavor  to  restore  the  broken  bones 
to  site,  the  septum  should  have  as  much  attention  as  the  contain- 
ing walls  of  the  nose. 

After  the  restitution  of  the  broken  nose  to  form,  means  must 
be  employed  to  prevent  the  part  from  becoming  misshapen 
through  displacement  of  the  bones;  such  displacement,  it  is  true, 
cannot  arise  from  muscular  action,  as  occurs  in  the  case  of 
fracture  elsewhere;  yet  the  prominent  and  exposed  site  of  the 
nose  renders  it  necessary  to  guard  the  parts  against  derangement. 
In  antiquity  we  learn  from  Hippocrates  that  many  forms  of 
contentive  appliances  were  used  to  retain  the  broken  nose  in 
proper  position;  says  he:  "Many  errors  are  committed  by  piiysi- 
cians  who  without  judgment  admire  beautiful  bandages,  and  who 
especially  pride  themselves  on  such  appliance  for  use;  for  this, 
bandages  of  the  most  varied  forins  are  used ;  bandages  containing 
compresses,  and  in  rhomboidal  form,  so  disposed  as  to  present 
diversified  intervals  and  islets.  As  has  been  said,  those  who  pique 
themselves  upon  thoughtless  mechanical  display,  are  pleased  to 
meet  a  fractured  nose,  so  as  to  apply  their  bandage  to  it.  Then 
for  a  day  or  two  the  physician  struts  in  delight  of  his  work,  and 
the  bandaged  patient  is  also  delighted;  the  latter  soon  gets 
annoyed  with  and  is  tired  of  his  dressing;  but  for  the  phj^si- 
cian  it  was  enough  to  have  shown  that  he  knew  hov/  to  apply 
remarkable  bandages.  Such  a  bandage  defeats  its  purpose;  for  if 
the  nose  has  been  flattened  by  the  fracture,  such  bandage  will 
render  it  more  sunken."  Celsus  counsels  to  maintain  the  broken 
nose  in  position  by  the  aid  of  an  adhesive  band,  wliich,  fastened 
to  the  nose,  is  to  be  attached  to  the  head  behind  the  ears.  Both 
he  and  Hippocrates  advise  to  support  the  fragments  b}'  means  of 
plugs  introduced  in   the  nostrils.      But   Hippocrates,  after  his 


332  NOSE    AND    NASAL    PASSAGES. 

satirical  dismissal  of  the  complex  bandages  then  used  as  retentive 
dressing,  says  that  uo  coutentive  api)aratus  is  equal  to  the  index 
finger  of  the  patient,  if  the  latter  be  attentive  and  constant. 
These  should  be  applied,  one  on  each  side,  and  retained  until  the 
cure;  and  if  the  patient  does  not  do  this,  the  soft  fingers  of  a 
child  or  woman  may  be  used  instead.  "Men,  though  they 
would  be  rid  of  deformity  at  any  price,  will  not  give  care 
and  attention  for  their  relief,  unless  they  suffer,  or  are  in  dread 
of  death."  Both  Hippocrates  and  Celsus  direct  that  sustaining 
plugs  of  soft  material  be  inserted  and  permitted  to  remain  in  the 
nose,  until  the  bones  heal;  such  obturator  was  made  by  Hippoc- 
rates of  whatever  soft  material  was  at  hand;  and  he  used  a 
portion  of  a  .sheep's  lung,  yet  he  preferred  a  plug  made  of  Cartha- 
ginian leather. 

These  ancient  methods,  as  detailed  by  Hippocrates  and  Celsus, 
contain  the  fundamental  elements  of  treatment  as  pursued  by 
the  modern  surgeon.  After  the  parts  displaced  by  fracture  have 
been  restored  to  normal  site,  they  must  be  retained  so  by  obtu- 
rating plugs  or  tubes,  which  are  in.serted  and  should  remain 
in  the  nostrils. 

The  obturating  supports  may  be  made  of  almost  any  material 
whicli  can  be  molded  into  cylindrical  shape;  a  convenient  article 
is  a  portion  of  a  cotton  roller.  This  should  be  rolled  into  a  hard 
cylinder  about  two  inches  in  length,  and  of  sufficient  thickness 
to  entirely  fill  the  nasal  passage;  in  the  bilateral  fracture,  two  of 
these  are  needed.  The  plug  should  be  saturated  with  an  alco- 
holic solution,  and  then  smeared  with  vaseline,  and,  thus  pre- 
pared, it  must  be  inserted  its  full  length.  In  the  young  subject, 
and  where  the  nose  is  small,  a  shorter  plug  should  be  used. 
As  the  outer  layer  of  the  obturator  may  be  displaced  in  its 
introduction,  it  is  well  to  first  wrap  a  fine  thread  around  it 
several  times;  and  nothing  is  better  for  this  than  the  thread 
which  can  be  detached  from  the  end  of  a  common  roller.  The 
little  cylinders  when  once  placed  can  be  retained  in  position  by 
a  strip  of  rubber  adhesive  plaster,  carried  acro.ss  the  nostrils  and 
fastened  to  the  upper  part  of  the  cheek.  These  plugs  should  be 
withdrawn  and  replaced  by  new  ones,  as  often  as  every  second  or 
third  day;  if  this  is  not  done,  they  soon  become  offensive  through 
the  .septic  matter  with  which  they  become  impregnated.  Instead 
of  this  solid  obturator,  a  hollow  one  may  be  employed.  This  has 
the  advantage  that  the  patient  is  able  to  breathe  through  the 
nose  instead  of  through   the  mouth,  as  he  is  compelled  to  do 


FRACTURE    OF    THE    NASAL    BONES.  333 

when  the  nostrils  are  wholly  occluded.  Such  hollow  plug  might 
be  made  of  a  section  of  a  quill,  which,  if  too  small,  could  be 
enlarged  by  wrapping  about  it  adhesive  plaster  or  a  strip  of 
cotton,  or  linen  cloth.  Such  hollow  obturator  might  be  con- 
structed of  India  rubber  or  metal;  but  as  each  case  demands  a 
tube  of  different  dimensions,  hence  the  surgeon  will  find  it  most 
convenient  to  extemporize  one,  adopting  one  of  the  plans  before 
mentioned. 

When  the  nose  has  been  restored  to  form,  and  remains  in 
shape  by  means  of  the  internal  supports,  nothing  more  is  required 
than  to  apply  to  the  part  cold  water  dressing.  It  is  rare,  how- 
ever, that  the  internal  support  alone  suffices;  to  prevent  the 
tendency  to  deviation  to  one  side  which  is  often  present, 
lateral  support  is  required.  Also,  where  the  injuring  violence 
has  depressed  one  nasal  bone,  and  elevated  the  other,  then,  a 
compressive  support  should  be  applied  on  the  uplifted  side,  so 
placed  as  to  maintain  slight  pressure  backwards.  Also,  if  the 
uplifted  bone  has  been  broken  into  two  or  more  fragments,  then 
such  lateral  compress  is  required  to  maintain  the  broken  parts  in 
level  position;  the  neglect  of  this  precaution  has  resulted  in  an 
irregular  form,  unsatisfactory  to  surgeon,  and  as  much  so  to  the 
patient. 

This  external  dressing  may  consist  of  two  small  rollers,  of 
length  equal  to  the  nose,  covered  with  adhesive  plaster,  with  the 
adhesive  face  turned  outwards;  and  these  adhering  compressive 
rollers  are  to  be  placed  on  each  side  of  the  nose,  and  retained 
there  by  transverse  strips  of  plaster.  The  adhesive  rollers  should 
be  of  equal  size  in  case  merely  lateral  support  and  protection  of 
the  injured  nose  is  required;  but  in  those  cases  in  which  one  side 
is  too  much  elevated,  and  must  be  repressed,  then  one  roller 
should  rest  against  and  press  on  this  side;  while  a  thicker  roller 
must  be  placed  alongside  of  the  bone  that  has  been  sunken,  and 
held  there  by  the  crossing  adhesive  strips;  thus  closed,  the 
uplifted  side  will  be  maintained  at  a  proper  level,  and  the  side 
which  tends  to  sink  will  be  protected  from  pressure.  Under 
such  treatment  the  fractured  nose  will  heal  in  a  period  of  three 
weeks,  in  the  adult,  and  in  a  less  time  in  the  child. 

Fracture  of  the  nasal  bones  is,  in  rare  cases,  associated  with  an 
open  wound  of  the  soft  parts  which  cover  them;  and  such 
wound,  as  a  rule,  is  of  lacerated  and  contused  species.  Such  a 
complication  is  certain  to  entail  an  unsightly  scar;  and,  besides, 
it  demands  a  slight  deviation  from  the  treatment  already  described 


334  NOSE    AND    NASAL    PASSAGES. 

for  subcutaneous  fracture;  for  after  the  fractured  bones  have  been 
restored  to  position,  and  provision  made  for  their  fixation  by 
plugs  in  tlic  nostrils,  attention  must  be  given  to  the  external 
wound.  If  there  be  hajuiorrhage,  this  is  to  be  controlled  by 
torsion;  and,  that  failing,  the  ligature  should  be  ap})liod.  Con- 
tused and  fringe-like  margin  should  be  trimmed  off;  thus  the 
wound  is  converted  into  one  of  the  incised  type,  and  lifnling  with 
slight  scarring  is  favored.  Should  there  be  unevenness  of  sur- 
face of  the  broken  bones,  this  should  be  corrected  by  digital 
molding.  To  correct  gaping,  and  to  fix  the  edges  of  the  wound, 
fine  metallic  sutures  should  be  used;  and  these  should  be  so 
introduced  as  to  effect  accurate  coaptation  of  the  edges.  Lint 
saturated  with  alcoholized  water  may  be  used  as  an  external 
dressing.  If  a  fragment  of  bone  tends  to  rise  and  form  an 
uneven  surface,  this  must  be  corrected  by  pressure  over  the 
dressing,  maintained  by  a  bandage  transversely  applied.  Such 
dressing  must  be  examined  daily,  in  order  to  see  whether  the 
bones  remain  in  place.  After  three  days,  the  metallic  sutures 
may  be  removed,  and  fixation  continued  by  means  of  strips  of 
India  rubber  plaster  beneath  the  alcoholized  dressing.  By  such 
management  and  daily  observation  of  the  wound,  a  satisfactory 
cure  of  both  bones  and  soft  parts  can  be  secured. 

Growihs  affecthig  the  external  surface  of  the  Nose. — The  outer 
integument  of  the  nose  may  be  the  site  of  neoplasms,  benign  and 
malignant.  The  benign  growths  oftenest  seen  here  are  simple 
hypertrophy  and  angioma;  of  the  malignant  species  lu])us  is 
often  seen  here;  a  less  frequent  development  is  epithelial  cancer. 

Hypertrophy  of  the  lobule  or  lower  end  of  the  nose  occurs, 
in  those  who  have  passed  the  meridian  of  life,  and  who  have 
been  the  subjects  of  acne  rosacea.  It  is  occasionally  seen  in  the 
female,  who,  as  is  known,  is  sometimes  affected  with  this  acnaceous 
affection:  yet  in  the  majority  of  cases  of  nasal  hypertrophy,  the 
deformity  is  met  with  in  the  male. 

This  growth  involves  both  the  skin  and  the  subcutaneous 
tissue;  the  glandular,  vascular,  and  epithelial  elements  of  the 
skin  are  greatly  increased  in  volume.  This  structural  augmen- 
tation is  greatest  in  the  lobule;  yet  it  occurs  also  in  the  wings 
and  septum  of  the  nose;  and,  in  the  worst  cases,  the  entire  nose 
is  monstrously  enlarged.  Hyrtl  refers  to  instances  of  the  kind 
in  which  the  part  attained  such  dimensions  that  it  reached  to  the 
chin,  and  interfered  with  breathing,  eating,  direct  vision  and 
kissing.     For  suggestive  reasons  the  osculatory  functions  would 


GROWTHS    AFFECTIXG-    THE    XOSE.  335 

seldom  be  interfered  with.  The  hvpertrophr  then  may  affect 
partially,  or  totally,  the  nose;  or  it  may  appear  in  the  form  of  an 
isolated  growth,  of  which  there  may  be  one  or  several  on  the 
nose.  Such  tumor  consists  of  an  irregular  aggregation  of  small 
lobulated  masses;  and  it  may  be  pedunculated  or  sessile.  The 
growth  is  conspicuous  for  its  red  or  purplish  color  ;  it  is  tubercu- 
iated  or  uneven  in  surface,  and  is  in  a  high  degree  unsightly  and 
deforming:  in  the  male,  to  whom  facial  beauty  is  often  a  serious 
detriment,  the  enormous  nose  may  be  tolerated;  but  in  the  female 
the  deformity  is  such  as  to  extinguish  whatever  attractive  lines 
her  face  may  possess,  and  even  to  force  her  to  social  retirement. 

The  development  of  this  hypertrophy  is  promoted  by  what- 
ever induces  congestion  of  the  face,  for  example,  the  use  and 
abuse  of  spirituous  drinks.  Such  congestion  is,  at  first,  active  in 
character;  later,  the  dilated  vessels  remain  permanently  widened 
and  constantly  filled  with  blood.  Cases,  however,  have  been  seen 
by  the  writer  which  were  not  referable  to  irregular  regimen,  and 
which,  presenting  no  remarkable  enlargement  of  the  vessels,  the 
growth  was  pale  instead  of  florid  or  purple.  The  patient,  how- 
ever, should  be  advised  to  abstain  from  articles  of  drink  and  food 
which  cause  facial  hypersemia.  Tlie  subject  of  nasal  hypertrophy 
rarely  appeals  for  surgical  aid  until  the  growth  is  so  advanced 
that  some  radical  treatment  is  necessary  to  relieve  the  deformity: 
some  procedure  which  will  at  once  remove  the  excessive  structure, 
or  which  will  promote  its  atrophy.  As  means  which  might 
arrest  growth  and  lessen  the  existing  volume,  the  tincture  of 
iodine,  fluid  extract  of  ergot  or  ergotine,  and  Fowler's  solution 
of  arsenic,  may  be  employed  hypodermically;  from  two  to  four 
drops  of  one  of  these  agents  may  be  injected  into  the  enlarged 
structure  once  in  two  days.  If  inflammatory  action  is  awakened, 
the  injection  should  not  be  repeated  until  this  has  wholly  sub- 
sided. For  if  the  part  be  much  irritated,  suppuration  would  be 
caused,  and  destruction  of  a  portion  of  the  structure  would  ensue; 
thus,  though  the  hypertrophy  would  be  reduced,  an  unsightly 
irregularity  of  surface  would  result.  The  fluid  extract  of  ergot 
used  externally  will  reduce  the  growth. 

As  the  acnaceous  disease  which  usually  causes  the  hypertrojjhy 
has  been  plied  by  remedies  which  were  chiefly  remarkable  for 
their  number  and  ineffectiveness,  the  patient  is  probably  ready 
to  accept  treatment  which  will  at  once  remove  the  disease:  and 
hence  he  will  prefer,  or  at  all  events  he  will  not  decline,  a  resort 
to  the  knife.     The  hypertrophied  mass   should  be  reduced  by 


336  NOSE    AND    NASAL    PASSAGES. 

multiple  cuneiform  excision:  enough  being  removed  to  reduce 
the  nose  to  normal  form.  Inasmuch  as  it  is  difficult  to  know 
how  much  should  be  taken  away, it  is  better  to  operate  twice:  the 
first  time  doing  most  of  the  work,  and  later  finishing  it:  thus, 
cautiously  proceeding,  there  would  be  little  danger  of  rendering 
the  nose  too  small.  Tlie  long  axes  of  the  wedge-shaped  sections 
should,  as  a  rule,  correspond  witli  the  long  axis  of  tho  nose;  as 
exception  to  this  may,  perhaps,  be  a  section  removed  transversely 
from  the  tip  of  the  nose,  in  cases  in  which  the  no.se  remains  too  long 
after  tlie  longitudinal  exsections.  From  the  enlarged  septum,  a 
longitudinal  exsection  should  be  cut,  and  this  should  reach  in 
deep  enough  to  provide  an  ample  opening  for  the  nostrils.  The 
remaining  wounds  must  be  accurately  closed  by  fine  metallic 
sutures,  which  should  remain  in  site  for  one  week.  The  writer 
has  learned  from  experience  in  such  cases  that  accurate  closure 
of  the  wounds  is  no  easy  matter  where  several  broad  excisions 
have  been  made,  and  hence,  to  avoid  such  difficulty,  the  portions 
excised  should  not  be  broad,  and  each  gap  should  be  closed  as  it 
is  made.  In  thus  proceeding,  the  amount  of  tension  caused  by 
closing  the  wounds  will  appear,  and  allowance  for  the  same  can 
be  made.  The  scars  which  remain  after  healing  are  not  conspicu- 
ous, owing  to  the  vascularity  of  the  structure. 

Instead  of  total  enlargement  of  the  nose,  a  portion  of  it  may 
be  the  site  of  hypertrophy,  and  this  may  be  so  isolated  as  to 
resemble  a  pedunculated  growth.  In  such  isolated  hypertrophy, 
whetlier  sessile  or  pedunculated,  the  procedure  of  removal  would 
be  much  simpler  than  in  the  condition  of  total  hypertrophy. 
The  part  should  be  extirpated  by  an  oblong  circumscribing  cut, 
which  would  wholly  include  the  affected  part.  The  resulting 
wound,  from  its  elliptical  outline,  would  be  easily  closed,  and  the 
remaining  scar  would  be  linear  in  direction. 

Angioma. — The  nose  is  a  frequent  site  of  angioma.  This 
growth  nearly  always  dates  from  foetal  life.  And  every  grade  of 
it  is  seen,  from  the  merest  superficial  speck,  to  a  vascular  growth 
which  occupies  the  entire  thickness  of  the  nasal  wall.  When 
seated  superficially,  which  maybe  limited  or  cover  a  large  sur- 
face, the  nose  is  of  normal  size.  But  when  it  extends  througli 
the  greater  part,  or  the  whole  of  the  wall,  the  affected  part  is 
enlarged.  And  if  this  deep-seated  species  occupy  the  tip  of  the 
nose,  the  part  is  developed  much  beyond  the  remainder  of  the 
nose,  and  imparts  to  the  figure  of  the  infant  a  ludicrous  appear- 
ance.    As  tlie  venous  element   is  the  predominant  constituent, 


AXGIOMA.  337 

instead  of  the  red  hue  as  seen  in  the  superficial  species,  this 
deep-seated  variety  presents  a  bluish  or  cyanosed  hue. 

Treatment. — This  vascular  development  can  be  removed  by 
subcutaneous  ligation,  or  by  partial  or  total  excision.  Since  sub- 
cutaneous ligation  leaves  but  few  scars,  it  may  be  tried,  though  it 
is  less  certain  to  accomplish  the  purpose  than  the  knife.  To  do 
it,  a  needle  armed  with  a  strong  thread  is  made  to  enter  and 
emerge  at  short  intervals,  around  the  border  of  the  angioma, 
until  it  emerges  at  the  point  of  entrance;  there  the  two  ends  of 
the  thread  lying  in  the  first  opening  made  can  be  firmly  tied. 
Care  must  be  used  not  to  overdo  this  work  of  concealed  circum- 
scription, lest  sloughing  be  caused.  The  writer,  however,  has 
employed  this  procedure  in  an  angioma,  which  occupied  the 
entire  nose:  and  his  experience  would  indicate  that  it  is  not  an 
easy  matter  to  wholly  arrest  the  supply  of  blood  to  such  struc- 
ture: for  the  atrophic  action  induced  was  insufficient,  and  it  was 
necessary  to  repeat  the  ligation.  It  is  probable  that  the  needle, 
reentering  after  emerging,  left  portions  of  the  periphery  unin- 
cluded.  After  the  work  is  thus  done,  the  part  should  be  dressed 
with  carbolized  vaseline.  The  case  should  be  kept  under  close 
observation,  and  should  it  appear  that  the  blood  suppl}^  has  been 
wholly  cut  off,  as  would  be  denoted  by  a  continued  cyanosed 
color,  then  the  ligature  should  be  divided,  so  that  the  constriction 
will  be  lessened;  and,  if  need  be,  the  thread  is  to  be  removed. 
On  the  contrary,  should  it  be  apparent  that  the  constriction  is 
insufficient  to  effect  the  purpose,  then  the  ligature  must  be  tied 
tighter.  From  what  has  been  said,  it  is  clear  that  the  work 
should  be  kept  under  close  observation;  and  the  ligature  is  finall}' 
to  be  removed  when  it  has  become  loose. 

Should  the  method  of  concealed  circumscription  fail  to  ac- 
complish the  extinction  of  the  angioma,  a  resort  to  the  knife 
should  be  had,  in  which  the  procedure  before  mentioned  used  in 
removing  hypertrophy  should  be  followed;  cuneiform  sections  of 
the  vascular  growth  should  be  excised,  and  the  wounds  made, 
accurately  coaptated  by  suture.  Yet  even  this23lan,  as  tlie  writer 
has  experienced,  may  not  effect  a  cure:  the  remaining  vascular 
structure  may  awaken  to  new  action,  and  the  unsightly  growth 
reappear.  In  such  case  the  last  refuge  of  the  patient  is  substitu- 
tion of  normal  tissue  instead  of  the  vascular,  by  rhinoplastic 
means.  The  material  for  replacement  may  be  obtained  from  the 
frontal  or  malar  regions:  preferably  from  the  cheek  adjacent, 
when  the  vascular  structure  does  not  occupy  the  entirety  of  the 


338  NOSK    AND    NASAL    PASSAGES. 

nose.  To  operate  thus,  the  angiomatous  structure  should  be  first 
excised,  and  the  haemorrhage  carefully  arrested:  and  for  this,  fine 
ligatures  may  be  used.  Next,  from  the  cheek  contiguous,  lift  up 
a  flap,  somewhat  larger  than  the  breach  to  be  filled,  and  fix  the 
same  in  place  by  sutures.  This  replacing  flap  should  be  so 
planned  as  to  have  its  pedicle  near  the  breach  to  be  filled:  and 
this  may  be  accomplished  by  having  the  pedicle  situated  near  the 
wing  of  the  nose,  and  the  body  of  the  flap  directed  towards  the 
malar  bone.  In  proceeding  thus,  the  wound  on  the  cheek  can  be 
so  closed  as  to  somewhat  support  the  flap,  and  to  leave  a  scar  on 
the  cheek  nearly  coinciding  wdth  a  natural  furrow  of  the  cheek. 

Li(jnis. — "Writers  are  nearly  in  harmony  in  makingtwo  species, 
or  rather  grades,  of  the  disease:  viz.,  lupus  ulcerans  and  lupus 
rodens;  and  in  whichever  form  it  appears,  the  disease  has  a 
selective  preference  for  the  nose  and  cheek  adjacent,  for  its 
development. 

Bacteriological  researches  prosecuted  b}'  Koch.Neisser,  Demme' 
and  others  have  determined  that  there  is  a  close  kindred  between 
lupus  and  tuberculosis.  Koch  obtained  cultures  from  the  two 
diseases  which  were  identical  in  character  and  action.  As  the 
result  of  these  investigations,  the  modern  pathologist  seems  justi- 
fied in  naming  lupus  a  tuberculosis  of  the  skin. 

Lupus  ulcerans  may  commenceon  the  dorsum,  point  or  wing 
of  the  nose.  It  maybe  situated  on  the  skin  or  the  mucous  mem- 
brane, or  simultaneously  on  both  these  surfaces. 

The  disease  begins  on  the  surface  as  minute  pa[)ules,  which 
enlarge  and  fusing  become  larger;  and  in  this  latter  form  they 
are  crowned  with  a  thick  epidermal  covering.  The  summits  of 
these  nodular  eruptions  pass  rapidly  through  a  vesicular  or  serous 
stage  and  become  pustules.  If  the  summit  of  these  be  removed, 
there  escapes  a  sero-purulent  fluid,  which,  drying,  the  partis  cov- 
ered with  a  brownish  crust.  If  this  crust  be  removed,  there 
remains  an  ulcer-like  surface,  which  bleeds  when  touched,  and 
Ijecomes  the  site  of  fungoid  granulations.  This  denuded  surface 
is,  at  first,  level  with,  or  perhaps  higher  than  the  adjacent  skin. 
The  bounding  skin,  though  red,  is  not  indurated.  Later,  the 
disease  penetrates  inwards,  and  in  time  destroys  the  skin;  and 
even  the  cartilage  and  bones  may  be  attacked.  This  ulcerative 
process  tends  to  move  laterally,  more  than  inwards,  so  that,  as  a 
rule,  the  supporting  framework  of  the  nose  is  not  destroyed;  and 
what  is  remarkable,  the  disease,  like  a  fire  on  the  prairie,  dies 
out  behind,  while  it  proceeds  onwards  in  its  destructive  work. 


LUPUS.  339 

The  scar  covering  the  healed  portion  is  thin,  and,  for  a  time,  per- 
mits the  subjacent  red  structures  beneath  to  be  seen ;  later,  the 
cicatrix  thickens  and  contracts  so  as  to  deform  the  part.  And, 
though  healed,  there  is  a  tendency  in  the  disease  to  reappear  in 
parts  in  which  it  has  previously  existed  ;  and  this  recurrence  is 
probable  where  there  remain  abnormal  hardness  and  redness, 
and  the  cicatrix  is  streaked  with  fine  vessels. 

It  is  sometimes  a  question  to  determine  whether  the  disease  is 
one  of  lupous  or  syphilitic  ulceration,  especially  so  in  a  patient 
of  syphilitic  antecedents;  yet  the  form  of  the  ulcer  in  the  two 
diseases  is  quite  different:  viz.,  the  syphilitic  ulcer  has  margins 
clear  cut,  steep,  well-defined,  and  the  adjacent  skin  stands  higher 
than  the  denuded  part;  while  lupus  has  no  definite  boundaries, 
the  point  where  the  disease  ends  being  hardly  distinguishable; 
and  the  subject  of  it  is  young,  in  many  cases  not  having  reached 
puberty;  hence  early  youth  and  ill  bounded  ulcers  would  prove 
the  case  to  be  lupous  in  character. 

Treatment. — Seven  months  prior  to  the  time  when  these  lines 
were  written,  the  world  believed  itself  in  possession  of  a  cure  for 
tuburculosis  whether  that  disease  be  in  lung,  joint,  skin,  or 
mucous  membrane;  and  the  discoverer  of  that  cure,  Robert  Koch, 
was  lifted  to  a  position  of  popular  eminence,  by  the  professional 
and  popular  press,  loftier  tlmn  that  ever  attained  b}^  any 
writer,  and,  it  may  be  added,  by  anyone  within  the  ranks  of 
medicine.  For  a  few  weeks,  the  radiant  personality  of  this 
physician  as  the  first  star  in  the  firmament  of  fame,  was  the  sub- 
ject of  reverent  admiration  of  all  eyes,  and  his  name  was  hourly 
spoken  by  every  tongue  of  the  civilized  world.  Yet  this  great 
medical  scientist,  who  had  already  secured  by  his  bacteriological 
discoveries  an  enduring  place  for  his  name  on  the  page  of  future 
medicine,  committed  the  error  of  announcing  as  fact  that  which, 
though  probable,  had  not  been  fully  demonstrated ;  tuberculin, 
the  remedy  announced  against  pulmonary  tuberculosis,  after  a 
test  by  trial  and  careful  use,  disappointed  the  hopes  which  had 
been  awakened:  so  that  to-day  the  clamors  of  fame  which 
recently  deafened  the  ear  of  Koch  have  subsided  into  expiring 
echoes;  and  have  almost  been  replaced  by  the  remonstrating 
murmurs  of  public  disapjDointment. 

Inasmuch  as  ulcerating  lupus  is  cognate  to  tuberculosis,  the 
remed}''  of  Koch  was  tried  against  it  also;  and  the  trials  made 
seem  to  indicate  that  tuberculin  may  arrest  or  even  extinguish 
this  form  of  lupus.     This  inoculation,  however,  demands  so  many 


340  NOSE   AND    NASAL    PASSAGES. 

precautionary  guards,  lest  the  reaction  caused  by  it  should  injure 
the  ])atient,  that  it  is  not  probable  tliat  it  will  ever  become  a  ]iop- 
ular  remedy  for  the  treatment  of  lupus. 

The  treatment  of  simple  ulcerating  lupus  should  be  both  gen- 
eral and  local.  General  remedies  should  be  given  to  combat  the 
scrofulous  diathesis  which  is  present;  cod-liver  oil,  iron,  bark, 
and  the  phosphate  of  lime  should  be  administered.  The  prepa- 
rations of  iodine  and  arsenic  may  also  be  given.  A  nutritive 
diet  should  likewise  be  used. 

As  topical  means  to  combat  the  local  destructive  ulceration,  a 
number  of  agents  may  be  selected  from  the  list  of  escharotics. 
In  the  initial  stage,  ere  the  disease  has  invaded  the  deeper  layers 
of  the  skin,  the  author  has  found  much  benefit  from  tlie  nitrate 
of  silver;  let  this,  in  small  cylinder  form  ground  to  a  point,  be 
thrust  into  the  affected  structure,until  this  is  thoroughly  destroyed. 
If  the  disease  has  advanced  further,  and  involves  tlie  deeper 
tissue,  then  a  more  active  escharotic  should  be  used;  and  yet  too 
much  destruction  must  be  avoided,  for  the  caustic  action  should 
not  penetrate  through  the  nasal  wall.  As  agents  which  will  not 
act  severely,  one  may  emyjloy  a  paste  of  charcoal  and  sulphuric 
acid,  of  which  a  layer  may  be  smeared  over  the  affected  surface, 
after  the  latter  has  been  curetted.  Or  a  paste  made  by  mixing 
three  parts  of  powdered  Radix  Sanguinariaj  Canadensis  w^ith  one 
part  of  potassa  fusa;  or  one  made  by  saturating  salicylic  acid 
with  creosote,  or  with  concentrated  carbolic  acid,  may  be  applied 
on  the  curetted  surface.  Or,  as  liquid  application,  one  may  use 
nitric  acid,  carbolic  acid,  or  the  acid  nitrate  of  mercury.  Finally, 
the  diseased  part  might  be  superficially  cauterized  witli  the 
ferrum  candens. 

From  his  experience  with  all  the  destructive  agents  mentioned, 
the  writer  would  counsel  the  use  of  the  mixture  of  Sanguinaria 
and  potassa  fusa,  or  of  that  of  carbolic  acid  and  salicylic  acid;  a 
paste  from  one  of  these,  applied,  destroys  the  diseased  tissues  to 
a  slight  depth,  and  forms  a  crust  w^hich,  scab-like,  adheres  for 
some  days  and  then  falls,  leaving  a  surface  which  heals.  As 
dressing  to  the  part,  after  the  eschar  is  detached,  one  may  use 
citrine  ointment,  diluted  with  an  equal  part  of  adej^s;  or  anoint- 
ment containing  five  grains  of  biniodide  of  mercury  to  the  ounce, 
will  promote  closure  of  the  wound.  In  the  selection,  use  and 
retention  of  the  topical  remedy  in  place  on  tlie  nose,  one  must 
bear  in  mind  the  intractability  of  cliildhood,  in  which  the  dis- 
ease often  occurs,  and  take  precautions  accordingly. 


LUPUS    RODENS,  OR    RODENT    ULCER.  341 

Lupus  Rodens,  or  Rodent  Ulcer. — This  disease  is  closely  allied 
to  epithelial  cancer.  It  is  probably  a  severer  form  of  ulcerating 
lupus.  It  is  cancerous  in  its  appearance,  cancerous  in  its  march, 
and  cancerous  in  its  destruction  of  parts.  Like  cancer,  it  nearly 
always  is  seen  in  those  who  have  reached  or  passed  beyond  fifty 
years  of  age.  Unlike  cancer,  it  is  seen  in  those  who  are  otherwise 
in  perfect  health;  and  it  rarely  implicates  the  lymphatic  glands. 

Rodent  ulcer  appears  on  the  nose  at  some  point  of  the  skin 
which  is  not  bordering  on  mucous  membrane,  and  is  oftener  an 
immigrant  than  an.  aboriginal  production;  for  it  occurs  more 
frequently  on  the  eyelids  and  cheeks,  and  then  it  passes  to  the 
nose;  and  yet  exceptionally,  the  disease  may  travel  from  the  nose 
to  the  structures  contiguous.  It  commonly  begins  as  an  isolated 
tubercle;  in  rare  instances,  other  tubercles  arise  around  the  first 
one.  The  tubercle,  whether  single  or  multiple,  does  not  undergo 
pustular  change,  but  its  summit  opens  fissure-like;  this  opening 
being  often  due  to  the  action  of  the  patient's  own  nails.  From 
his  observation,  the  writer  is  certain  that  the  initial  tubercle 
would  remain  for  a  long  period  a  harmless  growth  if  it  were  not 
stimulated  to  further  development  by  incessant  irritation.  Many 
examples  of  such  irritation  will  suggest  themselves  to  the  experi- 
enced physician;  there  is  one,  however,  to  which  reference  may 
be  made,  and  this  is  the  ill  custom  into  which  the  majority  of 
persons  fall  of  touching,  handling,  rubbing  and  scratching  an}' 
irregular  point  on  the  surface  of  the  face.  And  such  habit  once 
established,  is  nearly  incorrigible;  when  thought  is  absent,  the 
hand  without  voluntary  guidance  seeks  the  forbidden  part,  and  a 
nail  detaches  the  epidermal  covering.  A  patient,  with  such  rodent 
ulcer,  stated  that,  despite  the  sternest  efforts  of  self-discipline,  he 
found,  when  attention  was  withdrawn,  that  his  finger  would 
resume  its  forbidden  task ;  and  only  after  the  rodent  ulcer  had 
attained  a  dangerous  foothold  on  his  face,  and  fear  became  a 
diligent  ally  of  his  eff'orts,  did  the  patient  break  his  ill  habit. 

Finally,  the  initial  point  of  the  disease  begins  to  ulcerate; 
and  as  the  ulcer  advances,  the  new  growth,  in  the  form  of  dense, 
hard  tissue,  a];)pears  around  and  underneath  the  eroding  breach. 
The  neoplasm  with  its  following  ulcer  attacks  the  skin,  subcu- 
taneous fascia,  and  is  not  arrested  by  the  bones  which  occur  in 
its  pathway;  they,  too,  are  destroyed.  Thus  the  nasal  bones  have 
vanished,  and  the  destroying  disease  continued  its  course  of  ruin, 
until  it  has  reached  the  cranial  base,  which,  also,  it  perforated 
and  attacked  the  brain.     The  patient,  whose  face  finally  becomes 


342  NOSE   AND   NASAL  PASSAGES. 

indescribably  hideous,  often  enjoys,  otherwise,  excellent  health; 
and  the  lymphatic  glands,  of  which  the  afferent  absorbent  vessels 
lie  in  the  track  of  the  ulceration,  do  not  enlarge.  As  a  rule,  the 
patient  has  but  little  pain,  were  it  not  for  his  apprehensions  of 
the  future. 

The  picture  which  has  been  traced  of  rodent  ulcer  clearly 
distinguishes  it  from  the  more  simple  form  of  ulcerating  lupus 
and  syphilitic  ulceration;  the  mild  lupoid  ulcer  is  in  the  young- 
subject,  and  its  margins  are  not  so  hard,  nor  so  uplifted,  as  are 
those  of  rodent  ulcer;  and  the  syphilitic  ulcer  is  distinguished 
by  being  contagious  and,  also,  more  rapid  in  its  course. 

The  course  of  rodent  ulcer,  as  here  given,  is  that  which  one 
finds  described  by  the  English  authorities;  and  though  such  a 
form  is  sometimes  seen,  there  is  evidently  a  much  milder  species 
which  is  more  frequently  seen.  In  this  milder  species  the  dis- 
ease appears  as  an  isolated  tubercle;  this  tubercle  finally  becomes 
covered  with  a  dry  crust-like  eschar.  Other  tubercles  appear 
as  does  the  first,  the  whole  forming  a  confluent  mass,  whicli 
becomes,  like  the  primary  point,  invested  with  a  hard  brown  or 
black  epidermal  crust.  When  this  crust  is  detached,  specks  of 
pus  and  bleeding  points  appear. 

Treatment. — Inasmuch  as  the  severer  form  of  rodent  ulcer  is 
fatall}^  destructive  of  the  part  on  which  it  is  situated,  and,  if  its 
course  is  not  arrested,  ends  in  frightful  deformity  and  final  death 
of  the  patient,  it  is  clear  that  the  treatment  which  promises  the 
speediest  extinction  of  the  disease  should  be  resorted  to;  and  as 
such  means  are  the  knife  and  the  actual  and  potential  cautery. 
With  the  knife  the  work  can  be  done,  care  being  taken  that  the 
line  of  excision  be  well  in  the  sound  tissue.  The  writer's  experi- 
ence has  forced  him  to  regard  excision  as  uncertain,  and  less  to 
be  depended  on  than  the  cautery.  And  what  the  knife  (ferrum) 
cannot  cure,  the  Hippocratic  aphorism  tells  us  fre  can  cure. 
The  ferrum  candens,  if  properly  used,  does  its  work  effectively, 
yet  it  has  the  disadvantage  of  leaving  a  contracting,  shriveled 
and  scarred  surface:  a  species  of  tissue  which  is  arid  and  sterile 
ground,  ill  suited  for  the  reception  of  a  transplanted  rhino- 
plastic  flap.  For  the  reasons  mentioned,  the  surgeon  will  do 
better  to  employ  potential  cauterization  in  preference  to  the 
actual  heat,  and,  as  agent  for  this,  good  results  will  be  gotten 
by  applying  the  paste  composed  of  potassa  fusa  and  Sanguinaria. 
This  should  be  used  immediately  after  beinj;  prepared  ;  and  only 
a  thin  layer  of  the  agent  should  be  applied;  and  even  then,  the 


NOSTRILS    AND    THEIR    DISEASES.  343 

destructive  action  may  extend  through  tlie  nasal  wall.  A 
minute  breach  thus  made  might  be  neglected,  yet  a  large  one 
should  be  repaired  by  transplanting  upon  it  sound  tissue.  For 
the  treatment  of  the  milder  form  of  rodent  ulcer,  to  which  refer- 
ence has  been  made,  a  less  active  cauterization  will  suffice;  then 
one  may  use  the  paste  of  charcoal  and  sulphuric  acid,  or  that 
made  of  creosote  and  salicylic  acid.  Tt  is  sometimes  necessary 
to  repeat  the  use  of  the  escharotic,  reattacking  the  disease  when 
it  reappears. 

Carcinoma  of  the  epithelial  species  may  appear  originally  on 
the  nose,  or  by  transition  from  neighboring  parts,  viz.,  from  the 
cheek  or  lip.  In  its  initial  appearance  and  subsequent  develop- 
ment the  disease  closely  resembles  rodent  ulcer;  the  cancerous 
disease,  however,  differs  in  this  respect,  that  it  first  appears  on 
the  transitional  integument  which  lies  between  the  derm  and 
mucous  membrane,  viz.,  on  the  border  of  the  nostrils.  Thence  the 
disease  proceeds  laterally  rather  than  centrally,  and,  hence,  the 
title  of  cutaneous  cancer  is  sometimes  used  to  designate  it.  This 
cutaneous  cancer  sooner  or  later  manifests  itself  by  adjacent 
metastasis  in  the  neighboring  lymphatic  glands. 

Cancer,  here  as  elsewhere,  has  a  fatal  destiny;  yet,  akin  to  the 
fire,  which  begins  as  a  spark,  and  is  then  easily  extinguished, 
yet  later  a  brigade  of  firemen  can  hardly  arrest  it,  so  this  carci- 
noma, in  its  infantile  stage  as  an  isolated  fissured  tubercle  or 
wart,  can  easily  be  eradicated;  but  if  the  destruction  be  permitted 
to  proceed  until  it  has  poured  into  the  numerous  adjacent  lym- 
phatic streams  its  fertile  germinal  elements,  then  surgery  with 
all  its  arms  usually  suffers  defeat.  A  treatment,  similar  to  that 
indicated  to  be  used  against  rodent  ulcer,  should  be  resorted  to. 
The  part  must  be  well  curetted  and  then  cauterized  with  one  of 
the  escharotic  compounds  above  named;  and  should,  unfortu- 
nately, there  have  been  so  much  delay  that  there  is  already 
infection  of  the  neighboring  glands,  these  should  also  be  removed ; 
such  removal  being  donelesswith  the  hope  of  a  cure  than  of  staying 
the  disease,  and  giving  the  semblance  of  doing  something;  ut 
aliquid  fecissevideamur,  as  Hyrtl  says. 

NOSTRILS   AND   THEIR   DISEASES. 

Narrowness. — The  entrance  of  the  nostrils  may  be  abnormally 
narrow  or  entirely  closed;  and  these  maybe  congenital  conditions 
or  they  may  be  subsequently  acquired. 

The  unshapen  nose  of  the  infant  often  presents  nostrils  too 


344  NOSE    AND    NASAL    PASSAGES. 

ntirrow  at  their  entrance  for  free  breathing;  usually,  in  the  course 
of  development,  this  imperfection  is  rectified.  In  infancy  and 
childhood  narrowness  may  be  acquired  through  some  inflamma- 
tory or  ulcerative  disease,  situated  in  the  nostrils,  which,  in  the 
process  of  repair,  constricts  the  nasal  orifices.  Examples  of  such 
disease  are  scrofulous  inflammation  and  eruptive  cutaneous  affec- 
tions, as  variola,  impetigo,  rubeola  and  scarlatina.  The  scrofu- 
lous child  often  presents  a  nostril  denuded  of  its  mucous  coating; 
likewise,  rubeola  and  scarlatina  may  act  in  a  similar  way;  the 
result  being  as  the  surface  heals,  cicatricial  contraction  and  nar- 
rowing of  the  outlet  of  the  nostrils;  and  this  narrowness  may 
extend  some  distance  into  the  nasal  passages.  In  these  cases, 
during  the  period  of  repair  of  such  denuded  or  ulcerated  surface, 
the  tendency  to  constriction  should  be  resisted  by  the  introduc- 
tion of  obturating  plugs  which  will  retain  the  nostrils  of  proper 
calibre.  Such  obturator  should  be  tubular  or  hollow;  yet,  in  the 
want  of  these,  the  solid  form  may  be  used.  For  this  ])urpose  the 
writer  has  found  a  section  of  a  drainage  tube  to  do  the  work  sat- 
isfactorily. Such  tube  should  be  somewhat  larger  than  the 
nostril,  so  that  it  must  be  comj)ressed  before  it  will  enter;  and 
when  thus  placed,  the  elastic  walls  of  the  tube  exercise  continu- 
ous pressure  on  the  walls  of  the  nostril,  and  not  only  prevent 
closure  but  even  enlarge  the  opening.  During  this  dilating 
treatment,  the  affected  surface  of  the  nostrils  should  daily  be 
smeared  with  some  alterative  ointment;  for  this,  one  may  use  a 
dilute  mercurial  ointment;  or  an  excellent  application  is  an 
ointment  made  of  iodoform  and  cod  liver  oil;  also  an  efficient 
compound  for  this  purpose  consists  of  fifteen  grains  of  the  sub- 
iodide  of  bismuth  to  an  ounce  of  vaseline. 

If  the  contraction  be  great,  the  method  of  dilating  just  men- 
tioned will  be  insufficient,  and  a  resort  to  the  knife  becomes 
necessary.  In  such  cases,  in  1840,  Schmitt  announced  a  plan  as 
follows:  the  opening  is  to  be  enlarged  by  removing  sections  from 
the  nostrils,  and  then  tannin  is  to  be  applied  to  the  wound,  and, 
later,  nitrate  of  silver.  This  plan  has  the  objection  that  a  raw 
surface  is  left,  which,  in  cicatrizing,  contracts,  and  the  opened 
nostril  is  again  lessened  in  calibre.  A  better  plan,  as  the  writer 
has  found,  is  to  preserve  the  dermo-mucous  membrane,  and  after- 
wards use  this  for  covering  the  wound  made.  To  do  this,  first  lift 
up  a  flap  and  excise  structure,  in  shape  and  amount  sufficient  to 
enlarge  the  orifice,  and  then  fix  by  suture  the  flap  that  had  been 
formed.     The  structure  is  best  removed  from  where  the  nostril 


NOSTRILS   AND    THEIR    DISEASES.  345 

joins  the  posterior  wall,  that  is,  from  the  posterior  part  of  the 
outlet  of  the  nostril;  thus  done,  the  opening  will  be  elongated 
antero-posteriorly.  This  procedure  would  be  unsuited  for  cases 
in  which  the  narrowing  is  due  to  cicatricial  contraction;  in  such, 
the  opening  should  be  enlarged  by  excising  sections  of  the  orifice, 
and  patency  maintained  by  dilating  obturators. 

In  case  of  total  atresia  of  the  nostrils,  whether  congenital  or 
acquired,  the  imperforate  condition  may  only  be  superficial,  as  a 
membranous  operculum;  or  the  occluding  structure  may  extend 
some  distance  into  the  nostril.  In  such  condition  the  occluding 
material  will  require  to  be  excised,  and  the  passage  retained  open 
by  an  obturating  tube,  which  must  be  used  for  a  long  period.  In 
this  operative  work,  if  it  be  possible  to  cover  a  portion  of  the 
wounded  surface  with  dermal  investment,  the  restored  nostril 
will  be  more  apt  to  remain  permanently  open;  especially  so 
where,  the  occlusion  being  deep,  a  deep  and  extensive  excision  of 
the  parts  must  be  made. 

In  the  plastic  operation  of  restoring  closed  nostrils,  Velpeau 
and  Jobert  utilized  the  outer  wall  by  paring  and  folding  it 
inwards  upon  itself.  This  method  is  attended  with  the  incon- 
venience that  the  border  would  be  abnormally  thick,  and  the 
septum  would  prominently  protrude;  and  were  the  latter  removed, 
the  nose  would  attract  attention  by  its  shortness. 

The  sub-se[)tum  or  inferior  portion  of  the  partition  between 
the  nostrils  is  sometimes  so  pendent,  or  reaches  downwards  so  far 
beyond  the  other  portions  of  the  nose,  that  it  is  a  conspicuous 
deformity.  According  to  Blumenbach's  observations,  the  Hebrew 
race  is  distinguished  by  prominence  of  the  nasal  septum.  Cases 
may  occur  in  which  the  surgeon's  knife  may  be  asked  to  retrench 
the  superfluous  structure.  Such  was  the  case  in  the  patient  men- 
tioned by  Blandin  in  whom  the  prominence  of  the  sejjtum  was 
such  that  it  became  an  insuperable  obstacle  to  getting  a  wife;  the 
writer  would  add  that  a  few  cases  have  been  seen  by  him  in  which 
subjects  of  such  deformity  were  more  fortunate  than  was  the 
patient  of  Blandin,  since  they  found  escape  from  their  enthrall- 
ment  through  the  magic  of  coined  metals. 

Such  deformity  should  be  removed  by  an  operation  done  so 
nearly  within  the  nostrils  that  but  slight  marks  of  the  cutting 
will  afterwards  be  visible.  To  do  this,  the  author's  plan  is  to  let 
the  pendent  dermal  portion  of  the  partition  be  separated  from  its 
posterior  attachment,  and  be  dissected  so  as  to  hang  suspended 
from  the  tip  of  the  nose ;  next  a  section  sufficiently  large  must  be 
23 


34G  NOSE    AND    NASAL    1' ASS  AGES. 

excised  from  the  cartilaginous  partition  above  so  that  when  the 
pendent  flap  is  restored  to  place,  it  will  not  project,  but  conform 
to  normal  type.  The  coaptation  should  be  accurately  made,  and 
the  part  retained  in  position  by  fine  metallic  sutures,  which 
should  not  be  removed  before  one  week,  that  is,  when  union  is 
assured. 

Chassaignac  reports  operations  for  the  relief  of  prominent 
septum,  in  which  he  proceeded  somewhat  similarly,  yet  instead 
of  excising  a  section  of  the  septum  in  its  entire  thickness,  after 
uplifting  the  mucous  membrane,  he  pared  the  remaining  parti- 
tion laterally,  and,  thus  attenuated,  he  forced  it  into  position,  and 
then  replaced  on  this  the  flap-like  mucous  portion  which  had 
been  uplifted  from  the  septum.  The  mode  of  operating  before 
described  is  preferable  to  this  one,  since  the  surplus  structure  is 
wholly  renewed,  and  the  septum  is  at  once  restored  to  normal 

Deflection  of  the  Nasal  Septum. — Some  deviation  of  the  septum 
is,  in  many  cases,  congenital,  and,  as  a  consequence,  one  nasal 
passage  is  rendered  larger  than  the  other.  In  the  adult,  equality 
of  the  space  of  the  nasal  passages  is  rarely  found;  yet,  in  most 
cases,  the  difference  is  so  slight  that  the  subject  of  it  is  so  little 
inconvenienced  by  it  that  he  is  not  aware  of  his  condition,  since 
he  breathes  readily  through  each  side  of  his  nose.  Not  unfre- 
quently,  however,  the  deviation  being  congenital,  or,  having  com- 
menced in  childhood  as  the  consequence  of  some  accident,  con- 
tinues to  increase  until  it  nearly  or  quite  occludes  one  nasal 
passage.  Tliis  deflection  may  be  situated  deep  in  the  nose,  and 
is  then  unseen  unless  the  nose  be  turned  upwards;  it  may  then 
be  discovered  to  involve  the  deeper  portion  of  the  cartilaginous 
septum,  and  perhaps,  likewise,  the  bony  septum  Or,  instead  of 
this  deep  location,  the  deflection  may  be  in  the  outer  cartilaginous 
portion,  and  may  project  from  the  nostril  so  as  to  become  a  con- 
spicuous deformity,  in  the  shape  of  a  red  pouting  mass.  This 
protruding  structure,  more  commonly  occurring  in  the  boy,  is 
usually  mistaken  by  his  parents  for  a  neoplasm;  and  a  similar, 
though  less  excusable,  error  is  sometimes  committed  by  the  med- 
ical attendant.  And  such  error  is  apt  to  arise  in  cases  in  which 
the  deflected  part,  hitherto  unseen,  has  suddenly  appeared,  due  to 
tumefaction  from  irritation  or  inflammatory  cause. 

The  diagnosis  of  the  deflected  septum,  whether  the  deviation 
be  high  up  in  the  nose,  or  situated  at  the  outlet,  is  readily  made 
if  one  examines  the  two  nostrils.     The  convex  portion  is  lined  by 


DEFLECTION    OF    THE    NASAL   SEPTUM.  347 

mucous  membrane  which  is  continued  upon  the  parts  adjacent, 
and  in  the  other  nostril,  corresponding  to  the  deviated  part,  one 
finds  the  partition  hollow  from  inflection;  such  inflection  of 
the  septum  will  always  be  found  on  the  side  of  the  larger  nostril. 
It  cannot  be  a  nasal  polyp,  since  this  does  not  arise  from  the 
septum.  A  case  resembling  deflection  is  one  in  which  theie  is 
isolated  tumefaction  on  one  side  -of  the  septum  due  to  a  smtll 
abscess  or  heematoma  situated  there,  or  to  a  swelling  from  local- 
ized inflammation  of  the  mucous  membrane;  yet,  iu  cases  of 
abscess,  hsematoma,  or  localized  inflammation  on  one  side,  incui- 
vation  of  the  other  side  of  the  partition  would  rarely  be  present 

The  consequence  of  such  deflection  is  partial  or  complete 
closure  of  the  affected  nostril ;  in  such  nostril  the  nasal  excreta 
would  be  retained  unless  they  escaped  posteriorly.  Such  occlusion, 
according  to  Moleschott,  favors  the  development  of  the  nasal 
polypus.  And  should  the  unaffected  nostril  become  obstructed, 
the  patient  would  be  forced  to  breathe  through  the  mouth.  For 
these  reasons,  surgical  interference  in  such  condition  is  not  only 
justifiable,  but  necessary. 

Treatment. — The  rectitude  of  the  partition  may  be  accomplished 
in  several  ways.  An  attempt  dias  been  made  to  do  this  by  first 
crowding  the  deviated  part  into  proper  position,  and  retention 
there  by  means  of  a  tampon  introduced  into  the  nostril.  This 
plan,  the  writer  has  found  by  experience,  is  tedious,  painful  and 
unsatisfactory;  for,  though  the  deformity  be  thus  rectified,  it 
tends  to  recur.  Another  procedure  similar  to  that  of  Chassaignac 
already  mentioned,  is  that  in  which  the  mucous  membrane  cover- 
ing the  convexity  is  uplifted  flap-like,  and  the  subjacent  cartilage 
is  trimmed  off  so  that  the  partition  can  be  forced  into  position, 
and  the  flap  returned  to  its  place  and  held  there  by  a  plug  in  the 
nostril.  The  fault  of  this  plan  is  that  the  continued  compression 
may  cause  death  and  sloughing  of  the  part  pressed  on,  and  an 
opening  through  the  septum  will  remain.  Another  plan  which 
has  given  the  writer  satisfactory  result  is  to  make  a  long  oblique 
incision  through  the  deviated  part,  so  that  the  latter  can  be  recti- 
fied ;  and  when  this  is  done,  the  two  faces  of  the  obliquely  divided 
septum  will  slide  on  each  other,  and  then  a  retaining  plug  being 
introduced,  the  wounded  facets  may  unite.  In  this  sliding,  if  a 
wounded  part  should  be  displaced  upon  sound  tissue,  then  the 
latter  must  be  trimmed  off,  so  that  union  can  occur.  By  another 
method,  which  was  proposed  by  Adams,  a  star-shaped  cut  was 
made  through  the  septum  by  means  of  a  specially  devised  knife; 


348  NOSE    AND    NASAL    PASSAGES. 

thus  divided,  the  part  is  to  be  brought  into  position  and  retained 
so  by  ivory  plates  retained  temporarily  in  the  nostrils. 

Jurasz,  of  Berlin,  writing  in  1682,  on  this  subject,  finds  that  such 
deviation  is  commonly  situated  in  the  posterior  two-thirds  of  the 
cartilaginous  portion  of  the  septum.  If  situated  in  the  anterior 
third,  Jurasz  would  remove  the  prominent  part  by  excision;  but, 
to  correct  deviation  which  is  more  deeply  seated,  he  uses  forceps 
constructed  after  the  model  of  obstetrical  forceps,  one  blade  of 
which  is  to  be  introduced  into  one  nostril  and  the  other  into  the 
other,  and  the  blades  are  then  to  be  locked  and  compression  to  be 
made  by  means  of  a  screw  that  passes  through  the  handles.  This 
instrument  is  to  remain  in  place  for  three  days,  and  then  the 
rectitude  is  to  be  maintained  by  means  of  the  ivory  plates  of  Adams. 
A  more  radical  procedure  l)as  been  practiced  recently,  viz.,  to 
excise  the  deflected  portion  of  the  septum,  thus  forming  a  })erma- 
nent  opening  through  the  partition;  such  an  opening,  though 
causing  no  functional  disturbance,  has  the  objection  of  leaving  a 
lasting  defect.  Excision,  if  done,  should  be  partial  and  limited 
to  the  removal  of  the  outer  prominent  portion  of  the  septum, 
which,  sometimes,  protrudes  through  the  nostril,  and  occasionally 
is  accompanied  by  but  little  deflection  of  the  deeper  portion  of 
the  septum;  in  such  cases  (which  are  those  which  oftenest  ask 
surgical  aid)  the  mucous  membrane  should  be  uplifted  flap-like, 
wath  attachment  above,  the  cartilage  then  excised,  and  the  flap 
restored  to  place  and  fixed  there  by  suture. 

The  septum  is  the  occasional  site  of  what  is  named  purulent 
tumor  by  Beaussenat,  by  whom  the  disease  was  first  described  in 
1SG5.  Such  tumor  consists  of  a  collection  of  ])urulent  matter, 
situated  on  the  cartilage  of  the  septum,  underneath  the  mucous 
membrane.  As  there  is  not  room  for  the  mass,  it  swells  out  the 
nasal  wings  and  protrudes  from  the  nares.  Such  a  tumor  forms 
on  both  sides  of  the  septum,  and  ends  by  perforating  the  latter, 
after  which  the  two  intercommunicate.  The  purulent  content  is 
mingled  with  blood.  This  affection  commences  as  a  swelling  that 
is  red  and  dry;  meantime,  the  outer  wall  of  the  nose  may  be 
slightly  affected.  As  accompaniments  of  this  swelling  are  pain 
in  the  head,  lachrymation  and  intolerance  of  light.  The  swelling 
finally  becomes  so  great  that  the  nostrils  are  nearly  or  quite  closed, 
and  breathing  through  them  is  very  difficult. 

The  cause  of  this  swelling  is  often  a  traumatic  one  in  which 
there  has  been  a  contusion  or  fracture  of  the  nasal  skeleton;  it 
may,  likewise,  arise  from  a  coryza,  or  from  some  exanthematous 


DEFLECTION    OF    THE    NASAL    SEPTUM.  349 

affection,  as  rubeola,  scarlatina,  or  variola,  and,  lastly,  it  may 
proceed  from  a  scrofulous  dyscrasy  of  the  subject. 

These  tumors  are  polypoid  in  appearance,  still  they  can  be 
distinguished  from  the  polyp  in  this  that  they  are  redder  and 
always  spring  from  the  nasal  septum,  and  are  near  the  anterior 
outlet;  a  true  polypus  is  situated  deeper,  is  of  whiter  hue,  and 
springs  from  some  part  of  the  outer  wall.  There  commonly  coex- 
ist two  purulent  tumors  which  inter-communicate  through  the 
nasal  septum. 

Treatment. — Such  tumor  should  be  opened  and  its  contents 
evacuated;  and  if  this  be  done  early  in  an  acute  case  a  speedy 
cure  may  be  obtained;  yet,  if  the  case  is  neglected,  or  becomes 
chronic,  there  may  be  entailed  atrophy  of  the  cartilage  or  a  per- 
foration of  the  septum. 

Besides  this  j^urulent  tumor,  Beaussenat  describes  a  collection 
of  blood  (hse-matoma)  beneath  the  mucous  membrane  of  the 
septum,  which  is  caused  by  a  wound  or  blow.  This  swelling 
when  large  can  obstruct  respiration.  As  proper  treatment  of 
such  hsematoma,- it  should  be  opened,  emptied  and  the  wound 
brushed  with  the  tincture  of  iodine. 

Sir  A.  Cooper  has  described  a  fungous  tumor  of  the  nose, 
resembling  polyp.  The  writer  has  seen  a  similar  form,  which 
springs  from  the  septum,  is  unilateral,  and  nearly  or  quite 
occludes  the  nostril.  The  patients  were  chiefly  children,  though 
exceptionally  it  was  seen  in  the  adult.  Such  fungous  swelling 
may  be  treated  by  scarification  or  astringent  applications.  In 
the  adult,  free  scarification,  in  which  the  part  is  divided  by  a 
number  of  incisions  which  reach  through  the  swollen  tissue  to 
the  cartilage,  is  the  speediest  mode  of  cure:  cicatricial  contraction 
is  thus  induced,  which  speedily  lessens  the  swollen  part.  In  the 
child,  M'hich  is  less  amenable  to  operative  treatment  than  the 
adult,  topical  means  can  be  used  for  reducing  the  swollen  part, 
and  as  proper  agents  astringents  may  be  employed;  and  of  these 
one  of  the  most  effective  is  tannin,  A  mixture,  compounded  of 
glycerine  saturated  with  tannin,  may  be  applied  to  the  part, 
once  or  twice  daily,  on  a  pledget  of  absorbent  lint;  and  this 
may  be  used  as  adjuvant  treatment  where  scarification  has  been 
done;  and  in  any  case,  this  astringent  application,  to  be  effective, 
must  be  continued  for  a  number  of  weeks. 

The  nasal  septum  is  the  frequent  site  of  ulceration;  and  this 
is  nearly  always  confined  to  one  side,  and  is  situated  in  the 
lower  third  of  the  partition,  just  inside  of  the  movable  or  der- 


350  NOSE   AND   NASAL   PASSAGES. 

mal  extension  of  the  septum.  As  predisposing  cause,  there  may 
be  syphiHs,  scrofuhi  or  some  obscure  cachectic  condition  of  the 
patient  In  such  subjects,  the  nasal  excreta  collect  on  the  septuuL 
as  hard,  dry  and  adherent  crusts,  and  their  removal  often 
causes  some  abrasion  of  the  mucous  surface;  such  is  the  man- 
ner in  which  a  slight  lesion  arises  and,  having  commenced, 
enlarges  and  becomes  permanent  through  continued  irritation. 
And  as  an  indolent  ulcer  elsewhere  has  but  slight  tendency  to 
either  recede  or  advance,  so,  in  this  location,  it  may  remain  with  lit- 
tle change,  for  an  indefinite  period,  as  a  denuded  point  of  the 
mucous  surface,  covered  by  a  thin  crust;  yet,  exceptionally,  it 
may  penetrate  deeper  and  perforate  the  septum. 

This  little  ulcer  is  most  unfavorably  situated  for  healing, 
and  hence  it  often  remains  as  a  tiresome  annoyance  to  both 
patient  and  physician,  for  an  indefinite  period.  For  the  ulcer- 
ated tissue  soon  becomes  tolerant  of  the  local  remedy  used,  and 
ceases  to  respond  to  its  action;  and  hence  the  remedy  must 
soon  be  exchanged  for  another;  and  the  more  frequently  the 
remedies  are  changed,  the  sooner  will  a  cure  'be  obtained.  As 
means  which  may  be  tried  are  the  compound  tincture  of  benzoin, 
and  ointments  composed  of  thirty  grains  of  iodoform  or  subio- 
dide  of  bismuth  to  one  ounce  of  vaseline.  Ointments  of  tannin 
and  of  the  salts  of  mercury  may  be  tried ;  and,  as  before  indicated, 
these  several  remedies  may  be  successively  used  for  a  short  time, 
and  then  again  repeated.  The  most  difficult  cases  to  treat  suc- 
cessfully are  those  in  which  the  ulceration  has  made  a  breach 
through  the  septum,  and  the  destructive  process  continues  slowly 
enlarging  the  opening.  Should  local  remedies  not  arrest  the 
ulceration,  the  thermal  cautery  should  be  tried;  and  thus,  the 
surface  being  destroyed  in  which  there  is  jirobably  lodged  some 
parasite  or  other  agency  which  maintains  ulceration,  healing 
may  take  place  in  the  sound  structure  which  remains.  Some- 
times, in  spite  of  the  most  careful  management,  such  ulcer 
remains  stationary,  and  is  a  source  of  anxiety  to  the  patient  lest 
the  destruction  of  the  partition  may  proceed  so  far  as  to  permit 
the  nasal  dorsum  to  sink.  When  it  commences  in  the  anterior 
part  of  the  cartilaginous  portion  of  the  septum,  this  ulcerative 
disease  never  entails  the  sunken  nose,  unless  it  arises  from 
syphilis,  through  which  the  osseous  portion  of  the  septum  being 
also  attacked  dies  and  is  finally  ejected.  In  these  cases  of  ulcer 
of  the  septum,  with   whatever  constitutional   disease  the  ulcer 


NECROSIS    OF    THE    OSSEOUS    SEPTUM.  351 

may  be  associated,  the  latter  should  be  appropriately  treated,  for, 
if  a  military  simile  be  permitted,  it  would  be  folly  to  arrest  the 
individual  skirmishers  who  advance  in  front,  while  the  main 
force  of  the  enemy  lurks  in  immunity  behind. 

Necrosis  of  the  Osseous  Septum. — The  vomer  and  the  perpendic- 
ular plate  of  the  ethmoid,  which  together  form  the  bony  parti- 
tion between  the  nares,  are  the  subjects  of  disease.  This  disease 
is,  in  most  cases,  of  syphilitic  origin,  and,  in  the  form  of  gum- 
matous deposit,  this  usually  appears  in  the  soft  parts  which  line 
the  bone.  This  disease,  in  its  course  in  the  soft  parts,  often 
deprives  the  bone  of  its  vascular  supply  so  that  it  dies,  and  this  is 
sometimes  on  so  large  a  scale  that  the  entire  bony  partition 
becomes  the  site  of  necrosis.  As  a  rule,  this  necrosis  is  only 
partial,  portions  of  the  bone  from  time  to  time  dying,  and  are 
detached;  and  for  the  complete  destruction  of  the  bony  septum, 
often  a  period  of  one  or  more  years  is  required.  Besides  con- 
stitutional treatment,  there  should  be  directed  to  the  part  topical 
remedies,  which  will  act  curatively,  and  likewise  deodorize.  As 
curative  agents  solutions  of  iodine  and  mercury  should  be  applied; 
an  excellent  mixture  is  one  composed  of  equal  parts  of  tincture 
of  iodine  and  the  tincture  of  nut-galls.  To  deodorize,  one  may 
use  the  compound  tincture  of  benzoin,  or  the  following: — 

I^.     Potassii  Permanganitis oij 

Aquae  Menthse  Piperitse ox 

Misce. 

Irrigation  with  a  solution  of  chloride  of  sodium  may  be  prac- 
ticed. In  spite  of  the  best  directed  efforts  of  treatment,  the 
bone  usually  dies,  and  fragments,  becoming  detached,  must  be 
removed.  The  patient  should  be  foretold  of  his  coming  mis- 
fortune, viz.,  that  the  dorsum  of  the  nose  will  probably  sink  and 
render  him  the  subject  of  unsightly  deformity;  thus  notified,  his 
impending  evil  will  fall  less  severely  on  the  victim. 

Obstruction  of  the  Nasal  Passages. — Golding  Bird,  who  has 
studied  the  causes  of  nasal  obstruction,  finds  that  these  may  vary, 
and,  according  to  symptoms,  may  be  classified  as  follows:  1. 
"Where  there  is  no  discharge  from  the  nostrils,  and  no  change 
occurs  during  alterations  of  the  atmosphere,  the  obstruction  may 
then  arise  from  necrosis,  sarcoma,  enchondroma,  deflection  of  the 
septum  and  thickening  of  the  inferior  turbinated  bone.  2.  In 
obstruction  from  a  mucous  polyp,  there  is  a  discharge  from  the 
nose;  and  the  condition  is  worse  in  bad  weather.     3.   In  long- 


352  NOSE    AND    NASAL    PASSAGES. 

continued  nasal  discharge  from  the  posterior  nares  of  mucous  or 
purulent  content,  the  obstruction  may  be  from  an  adenoid  growth" 
in  the  posterior  part  of  the  passage.  4.  Tliere  may  be  a  chronic 
nasal  obstruction  situated  anteriorly,  attended  by  a  continuous 
muco-purulent  discharge  from  an  oziena  of  local  or  constitutional 
origin. 

Nasal  Polypus. — Among  these  causes  of  obstruction  of  the  nos- 
trils, the  most  common  is  that  produced  by  a  growth  named  poly- 
pus: an  ill  name,  since  this  tumor  is  rarely  many-footed  and 
many-branched:  characteristics  which  the  name  implies. 

Two  forms  of  nasal  polypus  are  met  with,  to  wit,  the  mucous 
and  the  fibrous  or  fibro-cartilaginous.  Hippocrates  says  that  the 
polypus,  when  it  arises  in  the  nose,  originates  from  phlegm, 
gives  obliquity  to  tlie  nose  and  disturbs  breathing.  The  brief 
and  erroneous  pathology  here  given,  which  finds  the  origin  of  the 
polypus  in  phlegm  or  mucus,  has  reference  to  the  easily  mastered 
pathology  of  the  ancients,  in  which  four  elements,  viz.,  blood, 
phlegm,  bile  and  atrabile  served  for  the  compounding  and  evolu- 
tion of  all  organic  structures  of  the  animal  body.  Through  the 
cribriform  plate  of  the  ethmoid  bone,  the  old  physicians  thought 
the  phlegm  was  decanted  from  the  brain  into  the  nose.  But 
Virchow,  Billroth,  Paget,  and  the  microscope  have  disturbed 
these  felicitous  simplicities  of  the  olden  times  and  given  us 
knowledge  nearer  the  truth.  Microscoj)ically  the  mucous  polyp 
is  found  to  consist  of  a  mesh  of  delicate  fibres,  analogous  to  con- 
nective tissue;  and  in  its  meshes  one  finds  a  liquid  or  semi-liquid 
material  in  which  are  seen  elements  round,  oval  and  fusiform. 
According  to  Billroth,  there  are  contained  h^q^ertrophied  mucous 
glands  in  clusters  in  the  polypus:  and  from  these  enlarged  glands 
vesicles  or  C3^sts  may  arise.  The  polypus  will  be  denser  or  softer 
according  as  the  fibrous  constituents  or  the  mucous  substance 
predominates.  Its  serous  content  and  the  lack  of  vascularity 
render  the  nasal  polyp  translucent.  When  its  form  has  not  been 
altered  by  compression,  the  polypus  has  a  singular  resemblance 
to  an  oyster.  Its  figure  may  be  changed  by  pressure  of  contigu- 
ous parts.  There  may  be  a  single  one,  or  several;  and  when 
multiple  they  lie  at  diff"erent  distances  from  the  anterior  outlet  of 
the  nose:  so  that  when  occupying  that  outlet,  if  one  be  removed, 
another  one  comes  into  view. 

The  mucous  polypus  may  arise  from  every  part  of  the  nasal 
passages  except  from  the  septum;  it  ma}'' arise  also  from  the  frontal 
sinus,  or  the  ethmoidal  cells,  and  pass  thence  into  the  nose.     The 


NASAL    POLYPUS.  353 

most  usual  origin  is  from  the  mucous  membrane  covering  the 
superior  and  middle  turbinated  bones,  as  well  as  from  the  remain- 
ing mucous  membrane  of  the  meatuses  bounded  by  these  bones. 
The  polyp  may  attain  such  dimension  that  there  is  no  longer  any 
room  for  it  in  the  passages;  it  may  then  pass  backwards  or  forwards, 
and  appear  in  the  pharynx,  or  protrude  from  the  nose  upon  the 
upper  lip.  By  inspiratory  and  expiratory  effort,  the  polyp  can  be 
drawn  inwards,  or  forced  outwards:  and  this  mobility  is  due  to  the 
j)olypus  being  pedunculated.  Yet  exceptionally,  the  polypus 
may  be  sessile,  and  then  it  is  less  movable.  The  soft  plastic 
structure  of  the  mucous  polyp  does  not  allow  it  to  compress  the 
adjacent  parts  to  the  extent  of  injuring  them  ;  the  nose  may  be 
more  rotund  on  the  affected  side,  yet  rarely  has  the  mucous 
membrane  been  found  ulcerated;  and  never  have  the  bones  been 
seen  diseased,  as  occurs  from  the  fibrous  polyp,  or  malignant 
growth ;  and  hence  the  mucous  polypus  is  not  regarded  as  a  seri- 
ous matter,  by  either  physician  or  layman. 

Symptoms. — The  presence  of  a  mucous  polypus  in  the  nasal 
passage,  as  soon  as  it  assumes  some  dimensions,  is  announced  by  a 
heaviness  and  fullness  in  the  affected  side  of  the  nose;  there  is 
sneezing  and  a  constant  mucous  discharge  from  the  part.  The  pa- 
tient thinks  he  is  "taking  a  cold ;"  and  his  medical  adviser  is  often 
similarly  misled ;  and  this  error  may  originate  in  the  circumstance 
that  the  trouble  has  become  worse,  seemingly,  from  some  atmos- 
pheric change.  The  eye  of  the  affected  side  is  often  red  and  tears 
flow  from  it.  One  of  the  most  notable  sj/mptoms  is  a  change  in 
the  voice;  this  is  nasal  in  tone.  The  voice  sounds  as  if  in  some 
way  it  were  mufEed.  The  complete  obstruction  of  one  side  of 
the  nose,  or  of  both  passages,  where  the  growth  is  bilateral,  com- 
pels the  patient  to  breathe  through  the  mouth  instead  of  through 
the  nose.  He  sleeps  ill,  being  awakened  by  his  own  snoring. 
When  the  growth  is  unilateral,  if  the  unoccupied  nostril  be 
closed,  the  patient  finds  that  he  can  not  breatlie  through  the 
affected  side.  The  sense  of  smell,  and  even  that  of  taste,  are 
impaired.  The  patient  imagines  that  his  nose  is  swollen,  or  is 
filled  by  some  foreign  material;  and  he  is  continually  endeavor- 
ing to  liberate  the  nostril  of  its  contents;  and  these  efforts  instead 
of  affording  relief,  only  aggravate  his  condition  by  increasing 
the  congestion.  The  frequent  irritation  of  the  swollen  part 
occasionally  provokes  bleeding.  This  condition  has  often  lasted 
for  a  long  period,  the  patient  being  ignorant  of  his  true  condition 
and  referring  his  trouble  to  "catarrh,"  which,  in  modern  times, 


354  NOSE    AND    NASAL    PASSAGES. 

has  been  added  to  the  category  of  aihnents  of  the  layman,  and 
made  to  phiy  an  important  part  in  his  ills  and  expenses. 

The  effects  of  tlie  polypus  are  so  nearly  analogous  to  those 
which  may  be  caused  by  deflection,  or  suppurative  tumor,  of  the 
septum,  that  error  in  diagnosis  has  arisen  from  careless  examina- 
tion, or  want  of  knowledge  on  the  part  of  the  medical  attendant 
from  whom  advice  is  sought.  ^  The  polypus  is  readily  distin- 
guished from  disease,  located  in  the  septum,  by  color  and  site; 
the  mucous  polypus  is  of  pale  hue  and  is  located  in  some  part  of 
the  outer  wall;  it  never  grows  from  the  septum ;  disease  or  deflec- 
tion in  the  septum  is  of  reddish  color,  and  its  investing  covering 
is  continuous  with  the  mucous  lining  of  the  septum.  A  not 
infrequent  error  in  diagnosis  is  in  mistaking  a  swollen  condition 
of  the  membrane  lining  the  inferior  and  middle  turbinated  bones, 
for  a  polypoid  growth.  Xot  unfrequently  from  congestion  of  the 
nasal  passages  the  blood  gathers  in  the  pituitary  membrane,  and 
then  the  latter  may  hang  pendent  from  the  lower  margin  of  the 
turbinated  bone;  and  the  pendulous  structure  can  readily  be 
moved  laterally,  if  touched,  with  a  probe.  The  rhinologist,  whose 
field  of  work  is  bounded  by  the  four  walls  of  tlie  nasal  passage, 
easily  recognizes  the  condition  present  through  the  intense  vascu- 
larity of  tlie  aff"ected  structure  and  its  blood-red  color  and  mobility, 
provided  it  does  not  wholly  fill  the  nostril. 

As  important  aids  in  seeing  and  determining  the  situation  of 
the  growth  are  the  nasal  speculum  and  direct  or  reflected  illumi- 
nation. Light  of  the  sun  or  from  a  lamp  can  easily  be  reflected 
into  the  nasal  passage  by  means  of  the  common  ophthalmoscopic 
mirror.  In  the  most  of  cases,  however,  when  the  patient  applies 
for  relief,  the  growth  has  attained  such  dimensions  that  it  can 
readily  be  seen  if  the  nose  be  so  uplifted  as  to  bring  th^  -massage 
within  the  range  of  the  eye. 

As  symptoms  and  characteristics  which  distinguish  the  mucous 
polypus  from  the  fibrous  and  other  growths  in  the  nasal  passages, 
Durham  gives  the  following:  The  pale  color,  the  semi-transparence, 
the  elastic  softness,  the  slowness  of  its  course,  the  absence  of 
haemorrhage,  the  continuance  of  good  health,  are  symptoms  which 
distinguish  the  simple  mucous  polypus  from  that  of  fibrous 
nature,  of  which  the  color  is  more  or  less  red,  and  light  cannot 
traverse  it;  and  the  fibrous  growth  has  a  dense  and  resistant 
structure,  and  one  which  is  not  affected  by  atmospheric  changes. 
Tlje  fibrous  polyp  also  grows  rapidly,  and  is  often  attended  by 
epistaxis.     And  if  the  growth  be  malignant,  it  is  distinguished 


NASAL    POLYPUS.  355 

"by  pain,  opaqueness,  hardness  and  immobility.  It  bleeds  easily 
if  touched,  and  the  discharge  from  it  is  fetid.  Again,  from  the 
mucous  polypus,  the  osseous  or  cartilaginous  tumor  is  distin- 
guished by  the  hardness  and  immobility  of  the  latter. 

The  mucous  polypus,  though  wholly  benign  in  character,  is 
exceedingly  troublesome  from  its  endowment  of  rapid  reproduc- 
tion, and  this  reproduction  is  usually  not  from  the  site  whence 
the  polyp  has  been  extracted,  but  recurrence  is  from  the  develop- 
ment of  scions,  or  other  polypi,  which  spring  up  alongside  of 
preexisting  polypi.  Hence,  not  unfrequently  he  who  is  once  the 
subject  of  mucous  polypus  remains  always  a  victim  of  this  fertile 
growth.  The  writer,  however,  has  known  exceptions  to  this,  in 
which  thorough  removal,  done  by  extraction  with  forceps,  was 
not  followed  by  a  return  of  the  disease. 

Treatment. — The  nasal  polypus  was  well  known  to  the  an- 
cients; both  Hippocrates  and  Celsus  have  chapters  devoted  to 
the  treatment  of  this  growth.  In  Hippocrates  one  finds  all  the 
elements  of  treatment  which  are  used  in  modern  surgery,  or,  if 
not  wholly  the  same  as  methods  now  used,  yet  sufficiently  sim- 
ilar to  have  suggested  them.  To  remove  the  polypus  which  is 
soft,  and  which  is  forced  out  and  again  withdrawn  in  expiration 
and  inspiration,  Hippocrates  directs  to  first  cut  a  round  section 
from  a  sponge  that  will  fill  the  nostril,  and  then  tie  to  this  four 
pieces  of  Egyptian  cord,  each  a  cubit  long,  which  are  knotted 
together  at  the  other  end;  next  attach  these  cords  to  a  metallic 
rod  (wire),  and  carry  them  through  the  nose  until  they  are  seen 
behind  in  the  mouth;  then  seize  the  cords,  and,  supporting  the 
uvula  by  means  of  a  forked  bone,  the  cords  are  pulled  upon 
until  the  polypus  is  extracted.  Arrest  the  bleeding  by  means  of 
lint  carried  in  with  the  rod;  and  finally  dress  with  a  mixture 
containing  copper. 

When  the  polypus  resembles  flesh,  and  is  hard  to  the  touch, 
Hippocrates  advises  to  pass  a  canula  to  the  tumor,  and,  through 
this,  cauterize  the  growth  with  the  hot  iron  three  or  four  times; 
treat  the  wound  with  black  hellebore,  and,  later,  with  the  com- 
pound of  copper. 

In  a  third  manner,  the  polypus  may  be  removed  by  means  of 
a  cord  made  from  a  tendon  or  nerve,  which  is  tied  into  a  loop  at 
one  end.  Carry  the  other  end  of  this  cord  through  the  nose  into 
the  throat  by  means  of  a  fenestrated  rod;  the  looped  end  of  the 
cord,  at  the  entrance  of  the  nose,  is  next  to  be  carried  around  the 
polypus  by  means  of  a  forked  sound,  and,  when  the  growth  is 


350  NOSE    AND    NASAL    TASSAGES, 

thus  caught,  the  cord  in  the  back  of  the  mouth  is  to  be  seized 
and  pulled  upon  until  the  polypus  is  withdrawn.  During  the 
traction  support  the  soft  palate  with  the  forked  bone,  as  was  done 
in  extracting  the  polypus  by  means  of  cord  and  attached  sponge. 

A  fourth  Hippocratic  procedure  was  as  follows :  There  are 
cases  in  which  the  polypus  appears  to  be  flesh,  yet  when  it  is 
touched  it  resounds  like  a  stone;  when  the  condition  is  thus, 
open  the  nostril  with  a  knife  and,  having  cleared  out  the  nose, 
cauterize  the  part.  Afterwards,  close  the  w^ound  with  suture,  and 
treat  the  former  with  an  ointment,  and  subsequently  with  a  mix- 
ture of  copper,  and,  finally,  complete  the  cure  wath  lead.  In  case 
the  nasal  growth  be  cancerous,  it  is  necessary  to  burn  it,  and 
afterwards,  apply  hellebore;  and  conclude  the  treatment  with 
copper  and  lead. 

These  extracts  from  Hippocrates  embody  the  essential  ele- 
ments of  the  treatment  of  nasal  growths  among  the  moderns. 

Celsus  briefly  gives  the  knowledge  of  the  Roman  physicians 
on  this  subject  as  follows:  The  polypus,  sometimes  white  and  some- 
times reddish  in  color,  adheres  to  the  bones  of  the  nose,  and  may 
appear  in  front  or  behind  where  the  breath  descends  from  the  nose 
to  the  fauces;  and  in  the  latter  position  it  may  grow  so  large  that 
it  becomes  visible  behind  the  uvula;  and  when  the  south  or  east 
wand  blows,  it  causes  strangulation.  It  may  be  hard  or  soft ;  the 
hard  species  obstructs  the  breath  more  than  the  soft,  and  widens 
the  nostrils,  and  is  of  the  nature  of  carcinoma,  and  should  be 
let  alone.  The  soft  species  is  to  be  cured  by  the  knife;  mean- 
time it  may  be  reduced  by  a  compound  of  lead,  lime,  and  other 
ingredients.  To  remove  this  grow^th  use  the  spatha  (a  spoon- 
shaped  instrument  similar  to  a  curette);  but  use  diligent  care  in 
the  removal  not  to  wound  the  cartilage,  since  this  heals  with 
difficulty.  When  the  polypus  is  detached,  remove  it  with  a 
hook-shaped  instrument.  The  subsequent  management  is  sim- 
ilar to  that  taught  by  Hippocrates. 

The  treatment  of  the  mucous  polypus  as  now  pursued  may  be 
placed  under  the  heads  of  non-operative  and  operative. 

As  non-operative  means  are  medicinal  agents  which  possess 
astringent  and,  in  some  degree,  escharotic  properties.  One  of 
the  best  for  this  purpose  is  tannin,  which  may  be  used,  when 
finely  powered,  as  a  snuff".  Powdered  Sanguinaria  may  be  used 
in  the  same  way.  A  solution  of  alum,  of  sulphate  of  zinc,  or 
one  of  the  chloride  or  subsulphate  of  iron  may  be  used;  yet  of 
the  agents  mentioned  tannin  is  the  best,  since  it  has  none  of  the 


NASAL    POLYPUS.  357 

objectionable  qualities  which  may  be  urged  against  one  or  more 
of  the  others.  These  agents  arrest  the  growth  of  the  polypus,  yet 
do  not  remove  it;  and  to  be  effective  they  must  be  continued  for 
along  period. 

As  operative  means  may  be  enumerated  excision,  extraction, 
or  plucking  out, ligature  or  snare,  and  cauterization:  methods,  as 
before  seen,  employed  by  Hippocrates  and  Celsus. 

Before  resorting  to  any  of  these  methods,  the  location  and 
site  of  origin  of  the  mucous  polyp  must  be  accurately  deter- 
mined; and  this  may  be  done  by  means  of  a  speculum  con- 
structed of  metal  or  India  rubber,  and  which  may  be  used  equally 
well  in  examining  both  the  auditory  and  the  nasal  passages. 
This  instrument  may  be  bivalvular,  with  handles  by  which  it  is 
held  in  the  hand;  or,  as  a  cylinder,  it  retains  its  place  when 
inserted  into  the  passage.  With  one  of  these  instruments,  by 
means  of  direct  or  reflected  light  (the  latter  is  better),  the  poly- 
pus may  be  seen,  and  its  situation  and  the  volume  of  the  growth 
estimated.  As  aid  in  this  search,  a  probe  may  be  used,  with 
which  the  pendulous  growth  can  be  moved,  and  the  fact  deter- 
mined whether  the  polypus  is  single  or  multiple.  These  circum- 
stances being  learned,  one  next  selects  a  method  for  the  removal 
of  the  polypus. 

The  Celsian  method  by  excision  was  done  by  the  Latin  phy- 
sicians by  means  of  a  species  of  spatula,  probably  spoon-shaped, 
with  which  tlie  growth,  being  detached,  was  afterwards  drawn 
out  by  the  aid  of  a  hook.  A  modification  of  excision  was  prac- 
ticed by  Dr.  Gross,  who  used  his  finger-nail  for  detaching  the 
polypus,  when  the  latter  was  thrust  into  the  throat.  The  plan 
of  excision,  or  better  named  curetting,  may  be  reserved  for  cases 
in  which,  after  the  body  of  the  growth  has  been  plucked  off, 
there  remain  peduncular  fragments.  When  the  location  of  these 
can  be  seen,  they  may  be  scraped  off  by  a  curette. 

Excision,  or  the  modification  of  it  mentioned,  is  rarely  used  ; 
removal  by  plucking  off  or  joulling  out  is  more  commonly  prac- 
ticed. Removal  in  this  way,  though  fiercely  decried  by  special- 
ists, will  remain  as  a  usual  method  of  getting  rid  of  tlje  nasal 
polypus.  It  is,  doubtless,  often  abused,  yet  this  should  n^t  forbid 
its  use.  The  abuse  consists  in  trying  to  remove  what  is  not 
clearly  seen,  and  in  doing  the  work  solely  by  traction;  no  attempt 
should  be  made  at  removal  unless  the  polypus  is  clearly  seen  and 
located.  And  this  may  usually  be  done  with  the  unaided  eye, 
if  the  other  nostril  be  closed  and  the  patient  then  force  air  out 


358  NOSE    AND    NASAL    PASSAGES. 

through  the  affected  side;  thus  the  growth  is  brought  into  view. 
It  should,  however,  have  been  remarked  that  in  few  cases  will 
this  strategem  be  needed,  since  commonly,  when  the  patient 
applies  to  the  surgeon,  the  polypus  is  plainly  seen  when  the  sub- 
ject's nose  is  uplifted. 

For  the  extraction  of  the  polypus,  special  kinds  of  forceps  have 
been  invented ;  these  instruments,  as  a  rule,  have  curved  blades 
which  are  serrated  and  fenestrated.  The  writer  prefers  a  forceps 
with  straight  blades,  the  rivet  or  lock  of  which  will  correspond 
to  the  outlet  of  the  nostrils,  when  the  instrument  is  intro- 
duced into  the  nose.  The  blades  should  be  flat,  well  fenestrated, 
and  broader  than  that  of  the  instrument  commonly  used  for 
extraction.  With  such  forceps,  standing  where  he  can  work  with 
facility  and  not  obstruct  the  light,  the  operator  closes  the  sound 
nostril  b}'  pressure,  and  directs  the  patient  to  force  the  air  out 
through  the  affected  side ;  as  this  expiration  is  being  done,  the 
surgeon  having  already  introduced  the  forceps  to  the  growth 
with  opened  blades,  and  the  pol3''pus  being  carried  into  the  grasp 
of  the  blades,  they  are  closed.  Done  in  this  way,  the  polyp  is 
caught  without  random  groping  for  it,  as  is  done  by  the  inexpert 
operator;  and  being  caught,  the  surgeon  extracts  by  first  twisting 
and  then  making  traction.  The  twisting,  to  be  effective,  must  be 
continued  until  the  torsion  has  reached  the  pedicle;  then  if  trac- 
tion be  made,  the  detachment  will  probabl3^be  at  the  peduncular 
insertion  of  the  polypus;  and  occurring  there,  there  will  be  but 
little  or  no  bleeding,  since  the  vessels  of  the  pedicle  have  been 
subjected  to  torsion.  Should  the  growth  not  be  entirely  removed, 
an  effort  should  be  made  to  extract  the  fragment  remaining, 
provided  there  be  not  much  haemorrhage;  if  there  be  bleeding  so 
as  to  conceal  the  interior  of  the  passage,  then  further  work  should 
be  deferred  until  the  morrow  or  a  later  day.  With  straight-bladed 
forceps,  there  is  but  little  danger  of  injuring  the  contiguous  vas- 
cular wall;  often  but  a  few  drops  of  blood  appear;  and  if  the 
operator  be  experienced  and  adroit  in  manipulation,  and  the 
patient  be  docile,  no  blood  at  all  may  follow  the  extraction.  The 
haemorrhage,  on  account  of  which  the  method  of  extraction  is  so 
violently  decried,  is  usually  due  to  an  awkward  hand,  impatience 
to  complete  the  work  at  one  sitting,  and  forceps  which  instead  of 
being  straight  are  so  curved  that  in  torsion  they  necessarily 
wound  the  contiguous  membrane.  The  writer  has  seen  this 
traction  done  so  dexterously  by  the  adroit  hand  of  Verneuil  that 
no  bleeding  occurred. 


NASAL    POLYPUS.  359 

A  third  method  of  removal  is  that  done  by  means  of  metallic 
ligature  in  the  form  of  a  snare.  This  method,  advocated  by 
Duplay,  and  now  practiced  by  the  specialist  of  nasal  disease,  is 
done  by  means  of  an  instrument  modeled  after  the  polypotome, 
invented  by  Wilde  for  removal  of  the  aural  polypus.  This  con- 
sists of  a  wire  folded  into  the  form  of  a  loop,  which  is  passed 
along  the  handle  through  canulated  openings  which  partially 
conceal  the  wire.  By  light  reflected  from  a  frontal  mirror,  the 
growth  is  located  and  the  noose  having  been  thrown  around  the 
polypus,  and  carried,  if  possible,  to  its  attachment,  the  wire  snare 
is  tightened,  and  the  growth  thus  severed.  By  this  means  those 
mucous  polyps  which  are  deep-seated,  and  inaccessible  to  the 
forceps,  may  be  removed  with  little  or  no  haemorrhage.  Though 
some  traction  can  be  made  with  this  instrument,  the  work  of 
removal  is  rather  done  by  section  of  the  tumor;  and  done  thus, 
there  must  remain  a  portion  of  the  pedicle,  when  an  early  recur- 
rence of  the  original  polypus  is  inevitable.  But  when  done  by 
extraction,  the  pedicle  is  commonly  eradicated,  often  with  a  frag- 
ment of  the  turbinated  bone;  conditions  which  insure  against 
re-growth  of  the  original  polyp,  and-,  perhaps,  of  scions  that  are 
near  it.  Hence  removal  with  the  snare,  winch  was  advised  by 
Hippocrates  in  a  reversed  manner  from  before  bacicwards,  will 
not  wholly  supersede  that  by  traction  and  torsion  done  by  means 
of  properly  shaped  forceps. 

Another  method  of  treatment  is  that  of  cauterization,  poten- 
tial or  actual.  Potential  escharotics  have  been  employed,  but  their 
use  is  nearly  abandoned.  Thudicum,  known  for  his  writings  on 
the  treatment  of  nasal  affections,  employs  the  thermal  cautery  to 
excise  the  polypus.  He  passes  the  loop  of  the  thermal  cautery 
around  the  growth,  and  effects  the  division  by  heat.  The  advan- 
tage claimed  for  this  method  is  that  it  is  free  from  pain  and  causes 
no  bleeding.  The  statement  by  Thudicum  that  one  polypus  was 
removed  by  fifty-five  sections,  and  in  another  the  thermal  loop 
was  introduced  thirty-three  times,  shows  that  the  excision  thus 
is  tedious,  and  that  the  operator,  to  be  proficient,  must  have  long 
training  of  the  hand. 

There  was  recommended  in  1862  by  Fredericq,  a  treatment  of 
the  mucous  polyp,  by  which  he  claimed  to  cure  without  an  opera- 
tion. For  this  purpose  he  employed  the  acid  chromate  of  potash, 
applied  to  the  growth.  In  this  way  twenty  cases  were  cured. 
The  remedy  was  used  in  the  form  of  a  concentrated  solution 
applied  on  lint  to  the  polypus.  In  case  the  remedy  caused  too 
much  irritation,  its  use  was  temporarily  suspended. 


360  NOSE   AND    NASAL    PASSAGES. 

After  the  removal  of  the  mucous  polypus,  treatment  may  be 
pursued  that  will  retard  the  return  of  the  growth.  For  this  the 
author  has  used  with  advantage  Radix  Sanguinariaj  canadensis, 
and  tannin.  These  agents,  singly  or  combined  in  equal  parts, 
should  be  used  as  snuff.  This  must  be  used  for  months,  and  the 
snuffing  done  several  times  a  da}'.  As  the  powder  accumulates 
in  the  nasal  passages,  these  should  be  cleansed  daily  by  irrigating 
them  with  a  current  of  warm  water.  This  irrigation  is  done  by 
utilizing  the  ])hysiological  fact  discovered  by  Weber,  that  when 
a  stream  of  water  is  carried  by  douche,  or  injected  into  one  nasal 
passage,  and  tlic  patient,  meantime,  breathers  througli  the  mouth, 
the  current  of  water,  after  reacliing  the  choanie  returns  tlirough 
the  otlier  passage,  escaping  in  front.  The  contact  of  the  ihiid 
with  tlie  upper  surface  of  the  pendulous  palate,  awakens  reflex 
action,  probably  through  the  filaments  of  the  glosso-pharyngeal 
nerve,  and  causes  muscular  contraction,  similar  to  what  occurs  in 
normal  deglutition.  By  utilizing  this  action,  the  nasal  passages 
may  be  effectually  cleansed,  and  also  medicated  fluids  can  be 
brought  into  contact  with  the  entire  inner  surface,  for  disinfec- 
tion or  other  purposes. 

Fibrous  Polypus. — The  fibrous  polypus  or  neoplasm  is  much 
more  formidable  than  tlie  mucous  polypus  just  treated  of.  These 
tumors,  according  to  their  site,  are  named  nasal,  naso-frontal, 
naso-maxillary  and  naso-pharyngeal.  The  usual  form  is  the 
naso-pharyngeal,  which,  though  occupying  a  naso-pharyngcal 
location,  may  exce])tionally  originate  outside  of  this  region,  and 
yet,  by  growth,  appear  there.  Nelaton  and  others  claim  that  these 
tumors  always  spring  from  the  basilar  process  and  body  of  the 
sphenoid  bone.  Exceptions  to  this  have  been  observed,  viz.,  tliat 
the  tumor  may  arise  from  the  sphenoidal  pterygoid  processes,  and 
front  face  of  the  superior  cervical  vertebrae.  Tliis  discrepancy  in 
respect  to  tlie  point  of  origin  has  originated,  as  Bryant  has  sliown, 
from  the  fact  that  the  tumor  may  have  more  than  one  site  of 
attachment,  the  secondary  ones  having  arisen  from  the  circum- 
stance that  the  growth,  as  it  develops,  may  come  in  contact  with 
other  adjacent  points,  and  contract  adhesions  to  them;  and  thus 
the  growth  will  appear  to  have  more  than  one  point  of  origin. 
Tlie  fibrous  polypus  primarily  arises  from  the  })eriosteum,  start- 
ing beneath  the  mucous  membrane,  and,  as  it  develops,  it 
carries  the  mucous  membrane  before  it,  wdiicli  often  becomes 
thickened  and  resistant.  In  structure  this  tumor  is  firm,  hard, 
and  sometimes  has  a  hardness  approaching  that  of  cartilage. 


FIBROUS    POLYPUS.  361 

Unlike  the  mucous  polyp,  tliis  one  is  inelastic  and  opaque.  It  is 
usually  red  in  color,  dark  or  lustrous  in  appearance;  yet  when  it 
is  removed,  its  color  is  gray  or  whitish.  In  three  cases  seen  by 
the  writer,  the  growths  had  this  whitish  or  cartilaginous  appear- 
ance before  detachment;  and  the  structure  was  not  very  vascular, 
as  seems  to  be  the  rule  in  most  cases.  One  surgeon  found  an 
artery,  as  large  as  the  ulnar,  on  the  base  of  the  tumor. 

Histologically,  the  chief  constituent  is  fibrous  tissue;  and  the 
tumor,  or  section,  presents  to  the  naked  eye  a  fasciculated  aspect. 
The  fascicles  are  arranged,  at  points,  concentrically;  and  if 
examined  carefully,  they  will  be  seen  to  converge  towards  the 
j)edicle  or  point  of  attachment.  The  microscope  usually  reveals 
only  the  elements  of  fibrous  tissue;  sometimes,  however,  the 
fibrous  constituents  have  a  fusiform  appearance,  in  which  there 
is  an  apjDroach,  in  form,  to  that  of  the  doubly  conical  nucleated 
cell  of  sarcoma;  and  this  form  is  closely  allied  to  the  malignant 
connective  tissue  growths;  and,  similar  to  these,  such  tumors  com- 
monly return  after  removal.  Some  claim,  as  Boyer,  that  the 
naso-pharyngeal  growth  can  lose  its  benign  character  and 
become  transformed  into  a  malignant  tumor;  a  more  rational 
conclusion,  however,  is  that  such  growths  are  primarily  malig- 
nant, and,  in-  their  development,  violate  none  of  the  canons  of 
pathology. 

The  fibrous  tumor  has  •been  seen  incrusted  with  calcareous 
matter  which  may  penetrate  some  distance  into  the  growth. 
Such  chalky  formation  might  Ije  precipitated  from  the  normal 
nasal  secretions. 

The  growth  of  basilar  origin  is  free  to  expand  in  any  direc- 
tion; but  soon,  from  contact  of  the  lateral  walls,  its  development 
is  directed  antero-posteriorly,  since  the  tumor  meets  no  obstruc- 
tion in  these  directions.  Perhaps  one  nostril  alone  is  occupied, 
and  then  the  septum,  inasmuch  as  it  can  offer  but  slight 
resistance,  yields,  and  is  forced  into  the  other  passage.  The 
tumor  coming  in  contact  with  adjacent  parts  becomes  adherent 
to  them.  If  the  growth  is  not  interfered  with,  the  outstretching 
processes  of  it  may  extend  forwards  and  appear  at  the  anterior 
nares,  and  forcing  the  lateral  walls  asunder,  enlarge  and  deform 
the  nose.  Or,  the  tumor  may  enter  the  maxillary  sinus,  and 
thence  proceeding  outwards,  uplift  and  change  the  form  of  the 
cheek.  Again,  it  may  develop  towards  the  eye,  and,  uplifting 
the  floor  of  the  orbit,  encroach  on  the  eye,  and  force  the  globe 
from  its  socket,  and,  producing  exophthalmic  deformitv,  finally 
24 


362  NOSE   AND    NASAL   PASSAGES. 

impair,  if  not  destroy,  vision.  And  in  this  situation  a  process 
having  ]>enetrated  the  frontal  sinus  may  seem  to  have  originated 
there.  Tlie  tumor  in  its  development  may  pass  in  a  direction 
entailing  yet  more  fatal  consequences,  viz.,  it  may  penetrate, 
through  erosion  of  the  base  of  the  skull,  into  the  intra-cranial 
cavity,  and  fatally  compress  the  brain.  In  all  tlieso  directions, 
whatever  osseous  structures  the  tumor  may  encounter  in  its 
march,  the  bone  is  gradually'  absorbed. 

As  results  caused  by  the  tumor  from  obstruction  of  the  nasal 
passages,  and  from  encroachment  on  parts  whicli  are  contiguous, 
the  following  may  be  enumerated :  obstruction  of  respiration, 
which  may  be  limited  at  first  to  one  nostril,  and  later,  to  both 
nasal  passages;  encroachment  upon,  and  occupancy  of,  one  or  both 
frontal  sinuses,  and  tlien  if  tlie  volume  become  enormous,  there 
is  upheaval  of  one  or  both  cheeks;  closure  of  tlie  lachrymal 
canal,  and,  as  result,  unilateral  or  bilateral  epiphora;  encroach- 
ment on  tlie  orbital  cavity,  with  displacement  of  the  globe  of  the 
eye,  forwards,  or  laterally;  penetration  into  the  cranial  cavity 
through  the  base  of  the  skull,  and  as  nerves  are  met,  there  will 
arise  impairment  of  their  individual  functions;  thus  the  trifacial, 
ocular  motor,  optic  or  olfactive  nerves  may  have  their  functions 
impaired  or  annulled.  And,  finally,  should  the  growth  enter  the 
cranial  cavity,  though  there  may  be  tolerance  of  the  pressure  for 
a  long  period,  finally,  signs  of  encephalic  compression  will 
appear.  When  the  tumor  develo[)s  in  the  choanse  and  entrance 
of  the  pharynx,  difficulty  of  deglutition  arises,  and  is  a  source  of 
mucli  discomfort.  In  the  pharyngeal  istlimus  in  which  the  paths 
of  air  and  food  cross  each  other,  there  must  be  no  impediment  to 
either;  and  the  presence  of  a  naso-pharyngeal  growth  introduces 
confusion  in  the  nicel}^  balanced  acts  of  reflex  automatism  seated 
there. 

In  the  early  period  of  development  of  this  growth,  the  symp- 
toms present  are  often  mistaken  by  both  patient  and  physician 
for  a  cold  or  a  catarrh  (as  the  popular  phrase  now  has  it);  yet,  at 
this  initial  stage,  the  frequently  recurring  epistaxis  should 
awaken  suspicion  of  a  growth  in  the  nasal  passages;  and  one 
which  is  of  fibrous  and  not  of  mucous  structure. 

The  naso-pharyngeal  fibroma  almost  always  occurs  in  the  male 
subject;  in  only  a  few  cases  has  it  been  observed  in  the  female. 
Probably,  some  structural  or  anatomical  reason  exists  for  this 
immunity  of  the  female;  3^et  none  has  been  offered.  Perhaps 
nature,  who  has  been  so  unfair  in  the  allotment  of  tasks  and 


FIBROUS    POLYPUS,  363 

burdens  between  the  two  sexes,  has  not  erred  in  this  instance,  in 
placing  the  load  on  the  stronger  shoulders. 

'  This  growth  is  seen  oftenest  in  the  young,  viz.,  between  the 
ages  of  twelve  and  twenty  years.  Of  one  hundred  and  sixty-four 
cases  collected  by  Durham,  one  hundred  and  twenty-two  had  not 
passed  the  twentieth  year  of  life.  And  in  this  period  of  exu- 
berant growth,  fibroma  or  enchondroma  may  develop  in  contigu- 
ous regions;  of  this  the  author  has  seen  the  following  example : 
A  purely  fibromatous  tumor,  as  large  as  a. pigeon's  egg,  developed 
in  the  zygomatic  fossa  near  to  the  pharynx.  Through  an  incision 
within  the  buccol  cavity,  this  tumor  was  reached  and  extracted, 
without  leaving  any  external  mark  of  the  work  done.  A  few 
months  afterwards,  there  was  discovered  a  naso-pharyngeal 
fibroma,  which  doubtless  had  coexisted  with  the  tumor  that  had 
been  removed. 

In  the  diagnosis  of  the  nature  of  the  growth,  a  matter  of  the 
utmost  importance  to  the  patient  is  to  decide  whether  the  tumor 
is  or  is  not  malignant;  and  as  signs  that  it  is  cancerous,  are  the 
following:  The  growth  is  in  a  subject  who  has  passed  the  middle 
period  of  life,  and  it  develops  rapidly,  and  is  accompanied  by 
keen  shooting  pains;  and  the  glands  adjacent  swell.  Tlie  can- 
cerous tumor  is  soft,  friable  and  ulcerates  at  an  early  period,  and 
the  subject  soon  presents  the  ashy  hue,  and  the  poor  health  char- 
acteristic of  the  cancerous  cachexy.  In  contrast  with  this,  the 
nasal  fibroma  occurs  in  the  young,  is  hard  in  structure,  does  not 
ulcerate  and  grows  slowly.  A  fragment  placed  under  the  micro- 
scope would  assist  in  determining  the  true  character. 

Yet  the  nasal  fibroma  is  not  a  harmless  invader;  when  it 
reaches  large  dimensions,  it  causes  frequent  epistaxis  which 
slowly  weakens  the  patient;  and  through  pressure,  it  causes  pain.. 
Such  tumor  protruding  into  the  pharynx  can  cause  suffocation; 
so  much  so  that  Gosselin  proposes  for  the  tumor  the  name  of 
suffocating  polypus.  Sudden  death  has  arisen  from  asphyxia 
thus  arising. 

Cases,  however,  have  been  seen  in  which  the  naso-pharyngeal 
fibroma  has  become  gangrenous,  and  thus  the  patient  has  been 
liberated  from  his  disease  without  medical  or  surgical  treatment. 
And  analogous  to  growths  whose  appearance  and  development 
are  limited  to  a  certain  period  of  life,  it  is  not  improbable  that 
this  nasal  growth,  having  attained  certain  limits,  may,  possibly, 
cease  to  grow.  Yet  these  fortunate  events  are  so  seldom  seen 
that  one  can  scarcely  hope  for  their  realization;  absolute  extinc- 


364  NOSE   AND   NASAL    PASSAGES. 

tion  is  rarely  seen;  and  recurrence  is  the  rule  unless  the  site  of 
origin  is  also  radically  destroyed  ;  and  this  leads  to  a  considera- 
tion of  the  means  of  treatment. 

Treatment. — The  tumor  must  be  attacked  operatively;  and  the 
operation  done  may  be  simple  or  palliative;  or  it  may  be  radical 
or  curative;  and,  as  the  latter  embraces  subsidiary  work  by  which 
the  tumor  may  be  reached,  it  is  named  complex  or  compound. 

The  simpler  operation,  in  which  the  work  is  limited  to  the 
mere  removal  of  the  growth,  without  any  attempt  to  destroy  the 
site  of  origin,  may  be  one  of  the  subjoined  methods:  excision, 
extraction,  ligation,  detachment  by  scraping  or  curetting,  and 
division  or  destruction  of  the  part  by  cauterization. 

Excision  may  be  done  by  means  of  scissors  or  knife;  it  is  clear, 
however,  that  the  almost  inaccessible  situation  of  the  growth  will 
interfere  with  the  use  of  these  instruments,  with  any  great  degree 
of  accurate  efifect;  in  the  majority  of  cases,  the  work,  at  best,  can 
only  be  blindly  done.  Another  objection  to  excision  is  the  danger 
from  haemorrhage;  for,  as  before  stated,  these  tumors  are  very 
vascular,  and  to  divide  such  structure,  where  the  vessel  could  not 
be  reached,  must  cause  severe,  if  not  dangerous,  haemorrhage.  If 
this  method  be  pursued,  the  operator  should  be  prepared  to  intro- 
duce, at  once,  a  styptic  tami)on,  and  such  a  one  is  best  made  of 
sponge  saturated  with  a  strong  solution  of  tannin,  alum  or  a  salt 
of  iron.  80  many  risks,  however,  surround  this  procedure,  that 
it  is  rarely  put  into  practice. 

Extraction  is  much  to  be  preferrea  to  excision,  for  relief  from 
this  tumor.  For  this  purpose,  strong  forceps,  such  as  are  used  in 
extracting  vesical  calculus,  should  be  used.  The  extraction  is 
done  from  the  pharynx;  in  the  exceptional  cases  in  which  the 
tumor  can  be  reached  anteriorly,  the  removal  might  be  done  from 
in  front  through  the  nostrils.  If  done  from  behind,  the  forceps 
should  have  a  curve  similar  to  that  of  one  form  of  forceps  used 
in  lithotomy;  for,  thus  shaped,  the  instrument  can  be  introduced 
through  the  pharynx  into  the  choanse,  and  the  growth  there  seized. 
The  detachment  should  be  accomplished  b}"  traction  combined 
with  twisting.  The  work  of  torsion  will  be  done  with  difhculty, 
if  the  tumor  be  impacted  in  the  posterior  nares,  or  have  processes 
reaching  into  the  adjacent  sinuses.  The  torsion  will  act  on  the 
footstalk,  and  close  the  vessels  contained  in  it.  The  difficulty  of 
reaching  the  growth,  of  getting  a  firm  hold  of  it,  and  of  severing 
by  pulling  and  twisting  the  strong  structure  of  the  tumor,  are 
serious  defects  to  this  method  of  removal;  yet,  if  the  growth  is 


FIBROUS    POLYPUS.  365 

pedunculated,  or  has  a  small  attachment,  then  this  method,  as 
a  palliative  procedure,  is  one  of  the  best  which  can  be  used.  It 
is  best  adapted  to  those  cases  in  which  the  tumor  having  sprung 
from  the  overhanging  basilar  process,  hangs  in  the  pharynx;  in 
such  condition  the  tumor  might  possibly  be  so  completely  ex- 
tracted that  it  would  not  recur.  ' 

A  third  method  of  removal  is  by  ligature,  which  has  been 
done  in  two  ways,  viz.,  one  in  which  the  ligature  acts  slowly,  and 
the  other  in  which  the  section  done  is  immediate. 

The  ligature  of  slow  action  may  consist  of  silken  thread  or 
wire.  The  work  of  throwing  the  ligature  around  the  base  of  the 
tumor  is  difficult,  since  the  operator  works  in  a  space  into  which 
he  cannot  see,  and  hence  the  casting  of  the  strangulating  loop 
around  the  growth  is  done  at  random;  work  in  which  "millions 
miss  for  one  that  hits."  And  when  the  noose  has  been  adjusted,  if 
the  cord  is  silken,  the  formidable  difficulty  arises  of  securely 
tightening  it  by  a  knot.  For  this  reason  a  strangulating  loop  of 
wire  is  better,  since  this  can  be  closed  by  twisting,  and  can  after- 
wards be  made  tighter  by  twisting  it  one  or  two  turns  more,  if 
additional  constriction  be  needed.  The  objections  to  this  method 
are  the  difficulties  that  attend  its  use;  and  after  the  tying,  the 
slow  detachment  is  attended  by  the  passage  of  foul  materials  into 
the  pharynx,  which,  being  swallowed,  or  entering  the  lungs, 
become  a  source  of  disease.  These  objections  have  caused  this 
method  to  be  nearly  abandoned. 

Immediate  or  instant  ligation,  by  which  the  tumor  is  detached 
at  once,  is  preferable  to  the  slow  mode  described.  The  detach- 
ment may  be  done  by  the  linear  ecraseur,  or  the  loop  of  the 
galvano-cautery.  The  same  obstacles  are  met  here  in  adjusting 
the  loop  as  in  the  slow  method,  and  the  division  will  more  prob- 
ably be  made  through  the  body  of  the  tumor,  than  through  its 
base;  and,  hence,  it  often  becomes  necessary  to  repeat  the  opera- 
tion on  the  remaining  peduncular  portion.  It  is  probable  that 
division  with  the  linear  ecraseur  would  be  more  effective  than  if 
made  by  means  of  the  galvano-cautery.  The  thermal  method, 
however,  seems  to  be  preferred  by  the  nasal  specialist. 

A  fourth  method  is  that  in  which  the  tumor  is  removed  by 
piecemeal  detachment:  a  procedure  which  may  be  accomplished 
by  scooping,  scraping,  curetting,  or  plucking  off  fragments.  The 
uterine  curette,  or  a  chisel-edged  instrument,  may  be  used  in  this 
work.  The  work  of  such  fragmentary  disintegration  is  necessarih^ 
slow  and  attended  by  considerable  loss  of  blood.     The  difficulty 


366  NOSE   AND    NASAL    PASSAGES. 

or  impossibility  of  wholly  removing  the  growth,  is  an  objection 
which  can  be  urged  against  this  one  as  against  all  the  other 
methods  which  have  been  enumerated. 

All  the  procedures  mentioned,  inasmuch  as  they  leave  the 
site  of  the  tumor  uninjured,  are  imperfect,  incomplete  and  unsat- 
isfactory to  both  patient  and  operator;  f(^r  in  the  trilogistic  ruloi 
of  safely,  speedily  and  happily,  the  operator  has  chief  pride  in  the 
middle  term  cifo;  and  as  to  the  patient,  his  chief  purpose  with 
his  physician  is  to  be  speedily  and  thoroughly  cured;  and  hence 
a  treatment  which  promises  but  transient  relief,  or  a  scries  of 
recurrent  operations,  will  surely  be  rejected  by  him  if  anything 
better  can  be  offered.  And  this  introduces  a  consideration  of 
those  methods  which,  though  radical,  severe  and  deforming  in 
character,  yet  insure  a  cure  to  the  patient. 

The  obstacle  to  a  cure  in  the  methods  before  mentioned  is  the 
impossibility  of  reaching  and  destroying  the  peduncular  ground 
whence  the  tumor  springs;  and  to  do  this,  some  pioneer  work  is 
needed  to  open  a  road  to  the  tumor  and  its  site.  For  this  j^ur- 
pose  a  subsidiary  operation,  sometimes  of  considerable  extent, 
is  needed.  Such  preliminary  work  may  be  done  in  three  direc- 
tions, and  according  to  the  route  taken  in  this  particular  work,  so 
the  method  may  be  named  the  nasal,  tlie  facial  and  the  palatine; 
and  of  these,  different  operators  have  offered  modifieations.  So 
numerous  are  the  latter,  that  a  monograph  devoted  to  this  sub- 
ject and  published  in  French  about  1870,  contained  some  score  of 
diagrams,  each  representing  some  surgeon's  preliminary  section 
to  reach  the  tumor. 

As  varieties  of  the  nasal  method,  the  following  merit  notice: 
In  1866,  CoUis  made  a  vertical  cut  alongside  of  the  nose  until 
he  reached  the  nasal  bone  and  nasal  process  of  the  superior  max- 
illary bone;  these  bones  were  next  sawn  through,  when  the 
base  and  side  of  the  nose  were  uplifted  and  the  whole  external 
nose  was  deflected  to  one  side,  so  that  the  interior  cavity  of  the 
nose  was  exposed  to  view,  and  a  growth  there  could  be  removed. 
Verneuil  advises  to  open  the  cartilaginous  portion  of  the  nose  in 
the  median  line,  and,  if  need  be,  continue  this  through  the  nasal 
bone,  and  if  further  opening  be  necessary,  to  resect  these  bones. 
Verneuil  lays  down  the  rule,  that  the  opening  suffices,  if  the 
finger  can  enter  through  the  orifice  made.  Oilier  proposes  a 
horse-shoe  cut,  the  branches  of  which  lie  on  the  sides  of  the  nose, 
and  are  united  over  the  root  of  the  nose.  The  nasal  bones  are 
next  cut  through,  and  also  the  septum  is  divided,  when  the  nose 


FIBROUS    POLYPUS.  367 

is  lifted  from  its  site  and  turned  downwards,  so  that  a  free  open- 
ing is  made  to  tlie  naso-pliaryngeal  cavity.  Langenbeck  per- 
formed a  similar  operation,  but  tbe  horse-shoe  was  reversed;  be 
severed  tbe  soft  parts  and  divided  the  nose,  so  that  the  nose,  with 
upward  attachment  remaining,  could  be  turned  upwards.  After 
tbe  removal,  by  either  tbe  method  of  OHieror  of  Langenbeck,  the 
nose  is  restored  to  its  normal  site  and  retained  there  by  sutures. 

These  methods  are  especially  suited  to  the  cases  in  wdiich  the 
tumor  lies  in  tbe  nasal  passages,  and  is  not  impacted  in  the  cav- 
ity, viz.,  in  tbose  in  wdiich  the  nasal  bones  and  adjacent  portion 
of  the  superior  maxillary  bone  are  forced  forwards.-  The  way 
towards  the  basilar  site  of  implantation  is  both  opened  and 
shortened;  and  one  is  enabled  to  directly  attack  the  greater  por- 
tion of  the  growth.  And  in  case  processes  of  it  cannot  be  re- 
moved, it  has  been  found  that  such  portions  may  atrophy,  and 
cease  to  be  troublesome,  if  the  central  mass  of  the  tumo^  has  been 
removed.  Besides,  if  it  be  necessarj'  to  enter  the  maxillary  sinus, 
this  nasal  route  oflFers  a  free  passage.  And  the  pterj^go-masillary 
fossa  is  penetrable  by  the  same  route. 

x\s  before  stated,  after  extraction  of  the  tumor,  which  will  be 
considered  later,  it  is  usual  to  repair  the  breaches  made  by  the 
preliminary  operation:  and  in  case  a  portion  of  the  nasal  wall 
has  been  destroyed,  this  is  to  be  repaired  by  some  of  the  proced- 
ures which  will  be  detailed  under  the  head  of  rhinoplasty.  The 
breach,  however,  is  not  always  closed;  in  cases  in  which  the 
removal  is  imperfect,  or  an  early  recurrence  is  anticipated,  the  plan 
has  been  j)ursued  of  leaving  the  breach  unclosed,  through  which 
the  cavity  could  be  inspected  from  time  to  time,  and  an  attack 
on  the  tumor  be  renew^ed,  in  case  of  its  regrowth.  Such  opening 
must  be  closed  by  strips  of  over-bridging  adhesive  plaster;  and 
at  a  later  period,  when  the  growth  is  found  to  be  extinct,  then 
permanent  closure  by  some  plastic  procedure  may  be  resorted  to 

Tbe  facial  method  of  operating  will  next  be  considered.     In 
this  method  the  preliminary  w^ork  of  pioneering  consists  in  pre 
paring  a  route  through  the  superior  maxillary  bone :  and  various 
modes  of  doing  this  have  been  proposed,  or  carried  into  effect. 

Tbe  entire  removal  of  the  maxilla  superior,  which  w'as  first 
done  by  Syme,  though  it  offers  ample  facility  for  removing  the 
tumor,  yet  the  patient  remains  deformed  beyond  rescue:  tbe  eye 
sinks  downwards,  and  may  be  lost ;  the  tears  escape  continuously. 
Such  total  ablation  interferes  v^'ith  mastication,  deglutition  and 
voice.     Hence,  to  avoid  tbese  defects  in  form  and  function,  a 


368  .>OSE    AND    NASAL    PASSAGES. 

partial  exsection  of  the  up}ier  jaw  has  been  done:  a  procedure  in 
which  the  orbital  and  palatal  portions  of  the  bone  are  preserved. 
But  it  has  been  found  thattliis  method  deforms  tlie  face  severely, 
and,  withal,  the  way  thus  opened  to  the  tumor  is  too  narrow  to 
permit  its  removal. 

The  next  modification  of  tlie  facial  method  is  that  of  tempo- 
rary resection,  in  which  a  portion  of  tlie  maxilla  superior  is 
excised,  yet  so  retained  in  connection  with  the  soft  parts  that  it 
can  afterwards  be  restored  to  site,  and  reunited.  This  has  been 
done  in  several  ways.  Dezanneau  thus  temporarily  resected  and 
afterwards  replaced  the  lower  half  of  the  jaw,  with  successful 
results.  Other  attempts  seem  to  have  been  less  fortunate:  the 
teeth  and  fragments  of  the  resected  portion  were  lost.  The 
resection  was  next  done  on  the  anterior  ftice  of  the  bone  by 
Langenbeck,  Esmarch,  Trelat  and  others.  Langenbeck  resected 
the  front  face  of  the  bone,  and  reflected  the  osteo-cutaneous  flap 
inwards,  while  Boeckel  reversed  the  work  by  reflecting  the  flan 
outwards.  The  removal  of  the  tumor  seems  to  have  been  easily 
done  by  these  ways ;  and  the  uplifted  flaj),  afterwards  being 
replaced,  readhered  to  its  former  site. 

The  writer  proposes  as  a  way  of  doing  this  work,  to  combine 
the  nasal  and  facial  methods;  for  this,  make  a  longitudinal  cut 
along  the  affected  side  of  the  nose,  its  entire  length;  saw  through 
the  nasal  bone  thus  exposed,  and  let  this  be  a  portion  of  the 
cutaneo-osseous  flap,  which  by  suitable  sawings  is  to  be  uplifted 
from  the  front  of  the  maxilla  superior.  The  next  incisions  must 
traverse  the  upper  jaw  transversely:  one  just  above  the  alveolar 
process,  and  the  other  must  lie  below  the  infra-orbital  border: 
thus  done,  the  nasal  and  maxillary  incisions  form  three  sides  of 
a  rectangle,  which  is  open  towards  the  ear;  operating  tlms,  the 
orbit  and  the  buccal  cavity  will  not  be  infringed  on,  and  a  satis- 
factory route  will  be  opened  to  the  growth. 

These  facial  operations,  however  well  and  conservatively  they 
are  done,  mu.st  deform  the  ftice  by  large  scars.  To  avoid  this^ 
the  palatal  method  may  be  resorted  to.  The  attempt  to  reach 
the  growtli  through  the  palatal  way  was  first  done,  by  Manne  of 
Avignon,  in  1747,  who  divided  the  soft  palate.  Dieffenbach 
operated  in  a  similar  manner,  yet  his  incision  did  not  divide  the 
soft  palate  wholly;  the  posterior  margin  was  left  intact.  This 
opening  being  found  too  small  by  Maisonneuve  and  Nelaton,  the 
latter  enlarged  it  by  extending  the  incision  into  the  o.sseous 
palatal  vault.     Yet  even  the  large  opening  which  is  thus  made 


FIBROUS    POLYPUS.  369 

is  sometimes  insufficient  to  permit  of  the  easy  removal  of  a  large 
tumor:  in  such  case,  the  removal  is  done  by  fragmentary  disin- 
tegration, and  may  be  attended  by  severe  haemorrhage.  The 
chief  defect  of  this  method  is  that  the  palatal  vault  is  so  injured 
by  the  perforation  made  that  it  cannot  be  repaired,  or  but  im- 
perfectly. This  breach  in  the  roof  of  the  mouth  is  a  source  of 
much  inconvenience  to  the  patient,  since  in  eating,  the  food  can 
pass  into,  and  remain  in,  the  nasal  passages.  The  attempts  to  close 
such  breach,  when  the  latter  is  large,  have  usually  failed. 

The  three  methods  which  have  been  considered  have  had 
strong  partisans  in  those  who  originated  them:  it  remains  to 
consider  which  one  should  be  chosen.  The  ruin  made  of  the 
palatine  vault,  usually  irreparable,  the  deformity  and  functional 
impairment  entailed  by  the  facial  method,  are  serious  objections 
to  these  two  plans  of  operating:  the  nasal  method  is  less  objec- 
tionable, and  is  the  one  commonly  selected.  Tillaux,  guided  by 
his  accurate  anatomical  knowledge,  says  that  the  nasal  route  is 
the  most  rational  and  direct  way  to  reach  the  point  of  implanta- 
tion of  the  naso-pharyngeal  tumor.  But  should  the  removal  of 
the  tumor,  through  fixation  of  its  processes,  be  impracticable  in 
this  way,  his  second  j) reference  would  be  for  the  palatal  route. 

The  route  being  opened  to  the  tumor,  there  are  several  ways 
by  which  the  removal  can  be  accomplished:  and  of  these,  the 
most  simple  is  that  by  traction  combined  with  torsion,  in  case  the 
volume  of  the  tumor  is  small  enough  to  permit  the  work  being 
thus  done.  The  haemorrhage  which  follows  the  removal  of  these 
tumors,  and  which,  in  several  recorded  cases,  has  ended  fatally, 
demands  the  most  serious  attention  of  the  operator;  and  as  opera- 
tive means  which  give  greater  security  in  this  direction,  are  the 
procedures  of  linear  ecrasement,  the  galvano-cautery  and  the 
simple  thermal  cautery.  And  of  these  methods  the  division  by 
heat  has  proven  safer  than  that  of  linear  crushing..  The  pedun- 
culated portion  of  the  tumor  being  included  in  the  looped  wire 
of  the  galvano-cautery,  the  detachment  can  thus  be  done  with 
but  slight  loss  of  blood.  In  most  cases  the  section  could  be  made 
conveniently  with  the  knife  point  of  the  thermal  cauter3^ 

The  removal  has  likewise  been  done  by  means  of  the  poten- 
tial cautery;  for  this  arrow-shaped  points  prepared  from  a  mix- 
ture of  chloride  of  zinc  and  wheaten  flour,  should  be  thrust  into 
the  tumor.  This  plan  is  less  practicable  than  that  of  the  actual 
cautery,  and  there  is  tlie  danger  inseparable  from  it  that  some 
of  the  caustic  material  will  escape  into  the  throat,  and  pass  to  the 


370  NOSE   AND    NASAL    PASSAGES. 

stomach  or  lungs.  A  patient  treated  thus  died,  and  the  operator 
reported  that  the  caustic  agent  was  not  "foreign"  to  the  death. 

In  many  cases,  after  the  removal  of  the  tumor,  the  road  that 
has  b^eu  opened  to  reach  it  has  been  left  open  for  some  time,  in 
order  that  tlie  operation  shouhl  be  repeated  if  there  be  recurrence. 

The  nasal  fossse  are  the  site  of  malignant  growths,  of  which 
the  type  most  often  seen  is  epithelioma:  tlie  sarcoma  has  been 
observed.  These  tumors  apjiear  at  all  periods  of  life.  They  are 
found  so  adherent  to  the  bones  that  it  becomes  diflicult  to  decide 
whetlier  the  growth  originated  from  the  bone,  or  the  structures 
covering  the  bone. 

The  malignant  neoi)lasra  may  s})ring  from  any  portion  of  the 
inner  surface  of  the  nasal  cavity;  it  develops  rapidly,  soon  reach- 
ing the  ulcerative  stage,  and  bleeds  when  the  surface  is  scratched 
or  broken.  Durham  finds  that  the  veil  of  the  palate  is  red, 
tliickened,  and  distended.  The  special  origin  of  the  naso- 
pharyngeal fibroma,  its  advent  in  the  youthful  subject,  and  its 
slow  development,  distinguisli  this  growth  from  the  malignant 
growth.  It  is  true  that  each  type  is  recurrent,  yet  recurrence  of 
the  malignant  tumor  is  soon  concurrent  with  that  form  of  viti- 
ated health  named  the  cancerous  cachexy. 

Tlie  concealed  site  of  the  malignant  tumor  in  the  nasal  fossae 
lets  it  develop  for  a  time  unperceived:  this  circumstance,  and  tiie 
difficulty  of  radically  removing  the  tumor  in  its  labyrinthian 
retreat,  render  the  prognosis  of  sucli  growth  eminently  unfa- 
voral)le. 

The  treatment  described  for  the  removal  of  the  naso- 
pharyngeal growth  is  pro[)er  for  any  form  of  malignant  disease 
located  here.  The  site  of  origin  must  be  destroyed;  otherwise 
the  removal  would  be  a  temporizing  culture  of  the  growth. 
The  osseous  ground  must  be  removed;  hence,  after  an  opening  has 
been  made  to  the  tumor  by  the  excising  chisel,  and  the  growth 
completely  removed,  extinction  is  best  insured  by  attacking  the 
osseous  site  by  thermal  cauterization. 

Hypertrophy  of  the  Nasal  Mucous  Membrane. — The  mucous 
membrane  of  the  nose  may  become  thickened  to  an  extent  which 
may  interfere  with  respiration.  And  as  the  growth  depends  on 
development  and  widening  of  the  vessels  of  the  membrane,  the 
condition  may  properly  be  named  vascular  hypertropliy.  This 
thickening  of  the  membrane  occurs  especially  on  tlie  inferior 
and  middle  turbinated  bones;  yet  when  prominently  present  on 
these  bones,  the  remaining  mucous  membrane  is  likewise  affected, 


BLEEDING    FROM    THE    NOSE.  371 

viz.,  that  of  the  septum  and  floor  of  the  passages.  The  hyper- 
trophied  membrane  hangs  pendulous  from  the  turbinated  bones, 
and  has  been  mistaken  for  a  polypoid  growth.  Such  pendulous 
structure,  however,  differs  from  the  mucous  polypi  in  being  sessile 
or  directly  attached  to  the  margin  of  the  bone,  instead  of  being 
pedunculated,  and  it  is  of  a  dark  red  color,  this  color  indicating 
that  the  venules  are  mainly  concerned  in  the  formation,  and  not 
the  muciparous  glands,  as  is  the  case  in  the  mucous  polypus. 

Besides  interference  with  respiration,  this  hypertrophied  for- 
mation seems  often  to  be  the  causal  agent  of  asthma,  through 
reflex  excitation.  For  these  reasons  the  surgeon's  aid  is  some- 
times appealed  to,  for  the  removal  or  repression  of  such  hyper- 
trophy. This  may  be  accomplished  in  two  ways,  viz.,  scarifica- 
tion and  cauterization.  The  procedure  of  scarification  is  adapted 
to  cases  in  which  the  subject  is  plethoric,  and  to  wdiom  the  loss 
of  blood  will  not  be  detrimental.  To  do  this  use  a  sharj)-edged 
scalpel,  and  make  rapid,  shallow  incisions  at  various  points  in 
the  swollen  membrane.  The  result  will  be,  for  a  few  minutes,  a 
free  bleeding.  This  escape  of  blood  will  lessen  the  volume  of  the 
structure,  and  the  bleeding  will  cease  spontaneously  in  a  few 
minutes.  The  loss  of  blood  will  be  lessened  if  cold  water  be 
applied  to  the  bleeding  surface.  There  will  result  from  the 
■wounds  made  a  gradual  contraction  and  lessening  of  volume, 
due  to  the  contraction  of  the  cicatrizing  structure.  This  contrac- 
tion can  also  be  accomplished  l)y  the  thermal  cautery,  with  which 
the  surface  may  be  burnt  at  numerous  points.  The  division  of 
the  surface  by  means  of  the  scalpel  can  be  done  more  readily 
and  easily,  and  the  lesion  made  can  be  measured  better  with  the 
hand  wdien  holding  a  knife  than  the  long  handle  of  the 
thermal  cautery.  As  topical  means  which  will  favor  the  com- 
pletion of  the  cure,  tannin,  or  a  solution  of  a  mineral  astringent, 
may  afterwards  be  applied  for  some  weeks. 

Bleeding  from  the  iVbse.— Nasal  bleeding  was  observed  by  Hip- 
pocrates, who  makes  frequent  mention  of  it;  he  named  it  hsem- 
orrhage,  a  term  which  has  acquired  a  much  broader  signification, 
viz.,  to  indicate  bleeding  from  any  source.  Several  names  have 
since  been  applied  to  it,  all  of  which  have  fallen  into  disuse 
except  the  term  epistaxis,  invented  by  Vogel  and  Pinel. 
Traced  to  its  Hellenic  origin,  this  word  means  "falling  drop  by 
drop."  This  name,  formal  and  pedantic  as  it  is,  has  crowded 
out  better  ones,  and  obtained  an  enduring  place  in  nomenclature. 

Bleeding  from  the  nose  was  given  high  diagnostic  meaning 


372  NOSK    AND    NASAL    PASSAGES. 

by  Hippocrates,  Celsus,  and  other  ancient  writers,  an  importance 
wliicli  the  moderns  have  failed  to  verify. 

Blood  to  the  interior  of  the  nose  comes  through  the  common 
carotid  artery,  and  is  finally  received  through  branches  of  the 
external  and  internal  carotid  arteries:  the  final  branches  of  supply 
being  the  ethmoidal  and  the  spheno-palatine  arterioles. 

The  greater  part  of  the  blood  comes  through  the  spheno- 
palatine, a  branch  of  tlie  internal  maxillary.  The  recurrent 
blood  traverses  venules,  which  accompany  the  arteries,  and  a  part 
of  it  returns  directly  to  the  heart,  while  a  2:)ortion  returns  indi- 
rectly through  an  intra-cranial  route.  As  a  result  of  such  ana- 
tomical arrangement,  when  there  is  congestion  in  the  district 
supplied  by  the  internal  maxillary  artery,  the  mucous  membrane 
of  the  nose  will  participate  in  the  same,  and  the  same  is  true 
when  there  is  hypersemia  of  the  district  supplied  b}^  the  internal 
carotid  artery. 

Haemorrhage  from  the  nose  would  seem  to  herald  its  coming 
by  certain  local  signs;  as  such  have  been  noticed  unusual  redness 
of  the  mucous  membrane,  a  feeling  of  tension,  heat  and  itching 
in  the  nose,  fullness  and  redness  of  face,  and  suffusion  of  the 
eyes.  As  further  concomitants  there  may  be  ringing  of  the  ears 
and  vertigo.  The  pulse  is  hard  and  full,  and  the  extremities 
may  be  cold.  Also,  signs  in  remote  portions  of  the  body  have 
been  observed;  a  remarkable  instance  is  glandular  swellings. 

The  advent  of  the  bleeding  is  peculiar,  for,  in  most  cases,  the 
stream  of  blood  breaks  forth  from  the  nostril  as  if  it  had  been 
pent  up  and  merely  awaited  an  outlet  for  escape.  It  escapes 
through  the  anterior  or  posterior  nares,  according  as  the  head  is 
inclined.  It  may  escape  from  one  nostril  alone  or  from  both, 
more  usually  from  one  alone.  After  the  blood  has  started,  it 
may  flow  slowly  or  rapidly,  according  to  the  character  of  the 
source.  If  the  point  of  origin  be  well  behind  in  the  foss?e,  or, 
even  if  it  be  situated  forwards,  and  the  patient  be  reclining  as  in 
sleep,  then  the  l^lood  will  not  be  seen,  but  it  wilL[)ass  backwards 
into  the  throat.  During  sleep  such  blood  has  slowly  passed  from 
the  throat  and  been  swallowed;  and  afterwards,  the  blood  being 
vomited,  the  source  of  it  has  been  thought  to  be  the  stomach. 
This  imperceptible  passage  of  the  blood  to  the  stomach  is  due  to 
the  fact  that,  in  the  dorsal  recumbent  position,  if  fluid  be  dropped 
into  the  nostrils,  it  w^ill  enter  the  pharynx  and  descend  to  the 
stomacli  without  any  effort  being  made  to  swallow.  And  as 
Hyrtl  observes,  nutritive  material  may  thus  be  given  in  cases  of 


BLEEDING    FEOM    THE    XOSE.  373 

trismus,  tetanus,  or  in  which  the  patient  cannot  or  will  not  open 
the  mouth;  the  precaution  to  be  taken  is  that  the  fluid  be  intro- 
duced drop  by  drop.  Or  the  blood  may  collect  in  the  throat, 
and  some  of  it  passing  into  the  windpipe  may  cause  coughing 
and  ejection  of  blood,  which  has  been  mistaken  for  pulmonary 
haemorrhage. 

The  amount  of  blood  which  may  thus  be  lost  may  vary  from 
a  few  drops  to  amounts  which  fall  within  the  incredible  and  fab- 
ulous: thus  in  the  Actes  de  Leipzig,  a  case  is  recorded  in  which 
a  man  lost  seventy-five  pounds  of  blood  in  two  days.  Such  a 
statement  is  more  suited  for  a  page  of  Munchausen  than  for  a 
work  on  medicine.  The  large  quantities  sometimes  seen  are  gen- 
erally augmented  by  the  addition  of  other  excreta. 

Usually, after  the  haemorrhage  has  continued  for  sometime,  it 
is  arrested  by  a  clot  of  blood  closing  the  nostrils;  but  as  soon 
as  the  patient  clears  his  nostrils,  which  the  interference  of  breath- 
ing leads  him  to  do,  the  bleeding  returns.  The  bleeding  may 
recur  several  times  during  the  same  day,  or  once  daily  for  a  period; 
and  this  daily  return  may  be  at  the  same  hour,  or  at  a  different 
one;  and  when  appearing  periodically,  it  has  been  cured  by 
quinine. 

The  amount  lost  may  be  so  great  as  to  become  dangerous  to 
life;  death  has  thus  arisen  from  s3aicope;  as  a  rule,  however,  the 
patient  nearly  faints,  and  rallies  again  if  the  head  be  lowered. 
As  before  remarked,  the  blood  may  escape  down  the  throat,  and 
enough  blood  be  swallowed  to  endanger  life;  such  bleeding  can 
be  discovered  if  the  pharynx  be  examined;  and  besides,  when  a 
considerable  Cjuantity  has  entered  the  stomach,  the  fact  is  revealed 
by  vomiting,  since  the  blood  coagulating  acts  as  an  emetic. 

Adopting  the  classification  of  the  varieties  of  epistaxis  as  given 
by  Jaccoud,  we  have  the  following:  1.  Traumatic,  or  from  ulcera- 
tion. 2.  Bleeding  from  a  morbid  condition  of  the  vessels.  3. 
From  a  mechanical  cause,  which  may  be  active  or  passive. 
4.  From  an  adynamic  condition  of  the  patient. 

1.  Bleeding  from  a  wound  of  the  nose  is  often  seen  in  the 
child  from  falls  on  the  nose,  in  which  the  nasal  bones  may  be 
broken,  or  merely  the  mucous  membrane.  Bleeding  may  be 
from  violence,  in  which  the  patient  in  falling  strikes  on  his  head 
or  other  portion  of  the  body,  and  is  the  subject  of  severe  concus- 
sion. Fracture  through  contre-coup  implicating  the  ethmoid  or 
sphenoid  bone,  has  been  revealed  by  haemorrhage  in  the  pharynx 
and  posterior  nares,  the  blood  then  escaping  from  the  nose.     An 


374  NOSE    AND    NASAL    PASSAGES. 

ulceration  of  the  mucous  membrane  from  any  cause  may  open  a 
vessel  and  cause  bleeding.  A  growth  in  the  nasul  fossjc  is  often 
indicated  by  bleeding. 

2.  Bleeding  from  the  nose  is  seen  in  the  subjects  of  haemophilia; 
viz.,  in  those  who  have  a  constitutional  tendency  to  bleed;  in 
such  subjects,  luemorrhage  occurs  from  the  most  trivial  wound  of 
surface,  so  trivial  often  as  to  be  indeterminable.  This  hajmor- 
rhagic  tendency  is  referred  by  Virchow  to  vascular  narrowing 
due  to  fatty  change  of  the  walls  of  the  vessels.  It  is  probable  tliat 
defective  coagulability  of  the  blood  has  a  causal  agency.  Such 
unfortunate  subjects  oftenest  bleed  from  the  mucous  membrane, 
and  especially  from  that  of  the  nose. 

3.  Bleeding  may  arise  in  what  may  be  designated  a  mechani- 
cal way,  through  active  or  passive  congestion.  As  examples  of 
active  congestion  are  those  caused  by  violent  expiratory  efforts, 
exposure  to  great  heat  or  to  great  cold,  and  breathing  a  highly 
rarified  atmosphere.  Thus  during  the  march  of  the  French 
army  in  Russia,  wdien  exposed  to  cold,  as  well  as  during  an 
African  campaign  when  exposed  to  heat,  nasal  liaanorrhage  was 
a  common  occurrence  among  the  soldiers.  And  the  blood  often 
bursts  from  the  nasal  mucous  membrane  at  great  elevations  where 
the  atmospheric  pressure  is  much  lessened;  often  witnessed  in 
passengers  who  pass  over  one  of  the  Peruvian  railroads,  built  over 
a  summit  of  the  Andes. 

This  active  congestive  epistaxis  is  seen  in  the  haemorrhage 
which  sometimes  replaces  the  menstrual  flow  of  the  female;  also 
in  that  supplementing  the  flux  from  haemorrhoids.  As  is  known, 
ha3morrhage  vicarious  of  menstruation  may  occur  from  the 
rectum,  lungs  or  nose;  in  a  large  list  of  such  cases,  Pueeh  found 
that  in  eighteen  cases  the  haemorrhage  was  from  the  nose.  Such 
vicarious  haemorrhage  announces  itself  at  its  approach  in  the 
female  by  a  sensation  dull,  heavy  and  sometimes  lancinating  in 
the  nasal  region;  there  is  present  the  general  lassitude  which 
heralds  the  advent  of  the  menses.  But  when  the  epistaxis  com- 
mences, these  local  and  general  symptoms  vanish.  The  amount 
of  blood  which  is  lost  equals  that  which  escapes  in  normal  men- 
struation; yet,  in  a  few  exceptional  cases,  the  quantity  has  been 
excessive  and  imperiled  the  woman's  life. 

Nasal  luemorrhage  may  result  from  cerebral  congestion,  also 
from  closure  of  the  superior  longitudinal  sinus.  It  has  occurred 
in  cases  of  leucaemia;  one  was  observed  by  the  writer  in  which, 
despite  all  efforts  to  control  the  bleeding,  the  young  subject  died. 


BLEEDING    FROM    THE    XOSE.  375 

In  leucsemic  hsemorrhage,  Jaccoud  finds  the  cause  in  obstruction 
of  tlie  capillaries  by  leucocytes. 

Nasal  bleeding  accompanies  hepatic  disease.  It  is  a  common 
accompaniment  of  icterus,  of  which  it  may  be  the  initial  herald, 
as  well  as  the  subsequent  attendant.  The  loss  of  blood  adds  to 
the  gravity  and  fatalit3''of  the  disease.  Nasal  bleeding,  according 
to  Monneret,  is  present  in  cirrhosis;  also  in  hepatic  congestion. 
The  bleeding  in  these  cases  has  been  referred  to  a  vitiated  change 
of  the  blood. 

Nasal  haemorrhage  occurs  in  disease  of  the  spleen,  in  which 
the  blood  has  been  morbidly  altered. 

Cardiac  disease  in  which  the  circulation  is  accomplished  with 
difficulty,  is  attended  by  epistaxis,  especially  in  the  latter  stages. 
The  same  has  been  observed  in  renal  disease  by  Bright,  Graves, 
Raver,  Virchow  and  Braun.  It  is  often  present  in  acute  Bright's 
disease.  Ursemic  poisoning  may  be  accompanied  by  nasal  haem- 
orrhage. 

Disease  obstructing  the  pulmonar}^  circulation  may  cause 
bleeding  from  the  nose. 

4.  In  the  fourth  class  of  nasal  hgemorrhage,  Jaccoud  finds  the 
cause  in  an  alteration  of  the  blood,  and  from  the  accompanying 
debility  he  names  the  cases  adynamic  epistaxis.  There  is  pres- 
ent, as  chief  causal  agency,  diminution  of  the  fibrin,  and  a  dissolu- 
tion of  the  blood-cells.  In  many  cases  which  he  calls  pseudo- 
hsemorrhage,  it  is  not  blood  but  colored  serum  which  exudes 
from  the  mucous  surfaces.  Yet  there  may  escape  blood  in  such 
cases,  and  its  escape  may  be  referred  to  an  alteration  in  the  walls 
of  the  vessels,  or  to  impaired  vaso-motor  innervation  leading  to 
vascular  rupture. 

Haemorrhage  of  this  character  may  be  a  prodromal  attendant 
of  fevers  and  of  exanthematous  aff'ections.  As  is  well  known, 
epistaxis,  as  pointed  out  by  J.  K.  Mitchell,  is  one  of  the  most 
trustworthy  indications  of  an  approaching  typhoid  fever.  Also, 
a  nasal  bleeding  is  a  common  precursor  of  scarlatina  and  rubeola; 
and  where  these  diseases  appear  in  their  malignant  form,  in  which 
the  eruption  presents  itself  as  a  dark  purple  redness,  there  is  a 
frequent  or  continuous  hsemorrhage  from  the  nose.  And  the 
same  is  the  case  in  variola,  when  it  appears  in  a  malignant  pur- 
pural  type.  Malarial  fever,  when  long  continued,  may  induce  a 
cachexy  in  which  there  is  frequent  bleeding  from  the  nose;  and 
such  bleeding  is  characterized  as  pernicious  haemorrhage. 

In  the  cancerous  cachexj^  there  is  often  nasal  hemorrhage. 


SJO  NOSE   AND    NASAL    PASSAGES. 

Also  ill  the  ill  conditions  of  the  blood  jiresent  in  scurvy,  chlorosis, 
purpura  luemorrhagica,  and  kindred  cachexies,  nasal  htemorrhage 
is  a  frequent  accompaniment. 

Nasal  luemorrhage  of  the  class  here  mentioned,  becomes  of 
diagnostic  importance  in  indicating  the  approach  of  disease;  and 
in  many  of  the  instances  cited,  it  is  of  prognostic  value  as  indic- 
ative of  grave  and  obstinate  disease,  which  sometimes  is  incura- 
ble, inasmuch  as  the  affection  depends  on  disintegration  or 
morbid  changes  in  the  blood-cells. 

Treatment. — The  diversity  of  causation  which  lias  been  pre- 
sented, frequently  connected  with  conditions  the  opposite  of  each 
other,  indicates  that  tlie  treatment  must  vary,  and  that  thought 
and  discretion  must  be  used  in  the  selection  of  curative  means. 

In  cases  in  which  the  cause  is  traumatic,  for  example,  as  is 
often  seen  in  the  child  from  a  blow  or  fall,  tlie  bleeding  soon 
ceases  spontaneously;  and  its  cessation  may  be  promoted  by  cold 
water  applied  to  tlie  part.  And  in  the  robust  and  plethoric 
youth,  who  is  reaching  the  adult  period,  when  the  structural 
development  and  sanguification  should  be  in  mutual  equipoise? 
it  sometimes  occurs  that  the  production  of  blood  exceeds  the 
demands  of  the  economy;  in  such  case  the  surplus  blood  may  be 
rejected  through  the  nose;  and  such  bleeding,  as  a  physiological 
aid,  should,  as  a  rule,  not  be  interfered  with.  Exceptions,  how- 
ever, are  sometimes  met  with,  when  the  nasal  bleeding  is  so  pro- 
fuse as  to  demand  treatment;  for  though  such  haemorrhage  does 
not  directly  menace  life,  yet  it  may  impair  the  health  for  a  long 
time.  In  such  subjects,  an  essential  point  in  the  treatment  is 
that  the  patient  should  rest  and  avoid  effort  which  causes  afEux 
of  blood  to  the  Iiead.  When  the  bleeding  appears,  cold  water 
may  be  snuffed  up,  or  injected  into  the  nostrils.  Should  this  not 
suffice,  a  mineral  astringent  may  be  added  to  the  water  that  is 
injected:  and  for  this  purpose,  alum,  in  the  proportion  of  fifteen 
grains  to  the  ounce  of  water,  may  be  employed. 

As  in  the  youth  who  has  excessive  sanguine  endowment,  so  in 
the  adult  of  middle  life,  the  nasal  ha3niorrljage  may  be  salutary: 
the  turgid  vessels  of  plethora  find  through  the  nose  a  convenient 
outlet:  and  interference  in  such  cases  has  met  with  a  severe 
rebuke  to  the  physician,  and  brought  disaster  to  the  patient:  for 
the  sudden  arrest  of  the  blood  has,  in  more  than  one  recorded  case; 
caused  a  rupture  of  a  cerebral  vessel,  with  death  from  apoplexy 
or  half  death  from  hemiplegia.  An  attention  to  the  resistance 
and  tension  of  the  pulse  preserit  in  such  cases  should  serve  as  a 


BLEEDING    FROM    THE    XOSE.  377 

monition  to  depletion,  if  nature  does  not  take  the  work  in  her 
own  hand;  and  such  conditions  of  tension  should  certainly  guard 
against  arresting  the  nasal  bleeding. 

It  would  be  unwise  to  arrest  epistaxis  which  is  the  initial 
symptom  of  a  fever,  or  exanthematous  affection.  Yet  in  a  scrofu- 
lous, scorbutic,  cancerous,  purpural,  or  leucsemic  cachexy,  the 
bleeding  must  be  arrested. 

AVhen  the  nasal  hsemorrhage  is  vicarious  or  supplementary  of 
the  menstrual  flux,  it  should  not  be  disturbed,  unless  the  loss  of 
blood  be  excessive;  then  it  must  be  controlled. 

Should  the  bleeding  recur  periodically,  then  it  should  be 
treated  with  quinine,  provided  there  be  no  existent  plethora 
contra-indicating  the  arrest. 

In  renal  disease  of  chronic  albuminuric  or  glycosuric  species, 
nasal  heemorrhage  should  be  repressed.  But  in  acute  ura^mic 
intoxication  a  nasal  haemorrhage  would  be  salutary,  and  should 
not  be  checked :  indeed,  if  it  be  scanty,  it  should  be  supplemented 
by  a  free  depletion  from  the  arm;  tlius,  as  the  writer  has  verified, 
eclamptic  convulsions  may  be  arrested,  and,  without  doubt,  the 
life  of  the  patient  saved. 

The  methods  of  arresting  nasal  haemorrhage  are  the  following: 
The  topical  application  of  cold  water,  styptics  in  solution  or  in 
substance,  cauterization  of  the  bleeding  point,  when  that  can  be 
found,  tamponing  the  nostrils  before  and  behind,  or  throughout 
their  entire  length,  compression  of  the  carotid  artery,  lifting  the 
arm  upwards,  and,  finally,  the  erect  position  of  the  entire  body. 

The  slow  irrigation  of  the  bleeding  nostril  with  cold  water 
often  suffices  to  arrest  the  hgemorrhage:  this  may  be  done  by 
means  of  an  irrigating  apparatus  suspended  above  the  head  from 
which  the  water  is  conducted  through  a  tube  into  the  affected 
l^assage.  Or  the  water  can  readily  be  pumped  into  the  nose  with 
an  elastic  tubular  syringe.  The  cold  fluid  should  be  carried  into 
the  affected  nostril;  or  into  one,  and  then  into  the  other,  in  case 
of  bleeding  from  both  sides.  The  discovery  of  Weber,  already 
referred  to  in  this  work,  that  a  fluid  thrown  into  one  nostril  will 
pass  to  the  choanse  and  return  by  the  other  nostril,  is  utilized  in 
this  irrigation. 

Beside  simple  cold  water,  the  irrigating  fluid  may  be  made 
more  effective  if  there  be  added  to  it  alum  or  subsulphate  of  iron, 
in  the  proportion  of  fifteen  grains  to  the  ounce  of  water.  Or  the 
astringent  and  styptic  material  may  be  used  in  the  form  of  a 
powder,  which  is  to  be  snuffed  into  the  nostrils.  For  this  purpose 
25 


378  NOSE    AND    NASAL    J'ASSAGES. 

alum  or  the  iron  salt  mentioned,  or  sulphate  of  zinc,  or  acetate  of 
lead,  or  tannin  in  pulverized  form,  may  be  snuffed  into  the 
nostril,  and,  coming  in  contact  with  the  bleeding  jwint,  there  will 
be  formed  a  clot  of  blood  which  will  temporarily,  or  permanently, 
arrest  the  lia3morrhage.  As  a  styptic  for  this  purpose,  tannin  is 
the  best,  since  it  exerts  no  corrosive  action  on  the  mucous  mem- 
brane, as  do  alum  and  the  salts  of  iron. 

From  observations  on  epistaxis  made  b}'"  Chiari  in  1883,  he 
found  that  the  bleeding  originates,  in  most  cases,  from  the  septum, 
and  that  an  inspection  will  reveal  a  bleeding  point  there:  or  if 
not  found  there,  it  will  be  in  the  floor  of  the  passages.  Dr. 
Simrock,  a  specialist  in  Xew  York,  has  also  found  that  the  bleed- 
ing point  is  usually  on  the  septum,  and  in  most  cases  this  is  near 
the  outlet.  These  specialists  advise  to  arrest  the  bleeding  by 
cauterization  of  this  point:  Simrock  touches  it  with  a  Dencil  of 
nitrate  of  silver. 

Should  the  methods  mentioned  fail  to  arrest  the  haemorrhage, 
or  should  this  be  so  profuse  as  to  admit  of  no  delay,  then  the 
tampon  may  be  employed.  This  may  be  done  by  completely 
plugging  the  nostrils  throughout  their  entire  length  :  or  the 
closure  may  be  done  at  the  posterior  and  anterior  outlets.  As 
material  for  the  tampon,  sponge  of  fine  texture  can  be  used  •  also 
surgeons'  lint. 

The  closure  through  the  entire  length  is  best  done  by  means 
of  a  narrow  strip  of  lint,  several  inches  long,  which  has  been 
saturated  with  sonie  astringent  solution,  as  of  alum  or  tannin. 
With  a  probe  or  attenuated  sound,  one  end  of  this  strip  is  carried 
into  the  posterior  2:)ortion  of  the  passage,  and  enough  is  thrust  in 
to  close  the  posterior  outlet.  The  plugging  is  continued  with  the 
remainder  of  the  strip,  until  the  nostril  is  entirely  closed.  And  if 
there  be  bleeding  from  both  sides,  the  other  passage  must  be 
treated  in  the  same  manner.  In  this  tamponing  occlusion,  the 
work  must  be  done  gently:  for  if  done  too  forcibly,  the  mucous 
lining  of  the  passages  will  be  lacerated  and  subsequent  bleeding 
promoted.  To  completely  close  the  rear  of  the  nostril,  the  di- 
mensions of  the  posterior  opening  must  be  known.  This  outlet 
in  the  dried  skull  of  the  adult  has  the  form  of  a  ])arallelogram, 
with  short  diameter  from  side  to  side:  but  in  the  living  subject, 
this  outlet  is  lined  by  mucous  membrane,  and  is  an  ellipse,  of 
wdiich  the  long  diameter  is  nearly  an  inch  in  length,  while  the 
short  one  is  nearly  a  half  inch  long.  Hence  the  occluding  tam- 
pon must  have  these  dimensions.     For  this  use,  sponge  of  fine 


BLEEDING    FROM   THE    NOSE.  379 

texture  answers  well.  To  introduce  this  tamponing  plug  one 
may  use  the  canula  of  Bellocq,  which  is  exhibited  in  the  accom- 
panying  figure.     This  is  an  ingeniously  contrived  instrument, 


Figure  4.     Representing  Bellocq's  canula. 


consisting  of  a  canula  in  which  there  is  concealed  an  elastic  coil 
resembling  a  section  of  a  watch-spring.  AVhen  the  canula  is  car- 
ried through  the  nostril  into  the  pharynx,  the  spring  is  thrust 
out  and  projects  forwards  in  the  oral  cavity,  so  that  the  tanipon- 
ing  plug  can  be  drawn  into  the  posterior  opening  and  left  there. 

The  surgeon  may  not  have  at  hand  Bellocq's  canula;  in  fact, 
other  means  may  be  devised  to  rej^lace  it.  For  this  purpose,  a 
wire  folded  on  itself  may  be  passed  along  the  floor  of  the  nostrils 
and  the  end  caught,  and  a  piece  of  occluding  sponge  attached  to 
it;  and  thus  the  wire  pulled  on  will  draw  the  sponge  into  the 
passage.  The  tampon  must  be  drawn  quite  into  the  passage 
Tlie  other  nostril  may  be  plugged  in  a  similar  manner;  and  to 
prevent  the  sponge  escaping  into  the  throat,  a  thread  attached  to 
each  one  may  be  tied  in  front  across  the  septum.  Instead  of  a 
wire,  a  convenient  means  of  carrying  a  thread  backwards  along 
the  floor  of  the  nostrils  is  a  small  soft  catheter,  or  a  piece  of  flex- 
ible whalebone.  When  the  posterior  passage  is  occluded,  the 
anterior  one  is  to  be  filled  with  occluding  material.  The  blood 
thus  having  no  egress,  clots  at  the  bleeding  point,  and  the  hemor- 
rhage is  thus  controlled. 

If  a  comparison  be  drawn  between  the  mode  of  continuous 
plugging  and  that  of  only  closing  the  anterior  and  posterior 
nares,  the  former  is  preferable,  for  the  following  reasons :  When 
the  entire  passage  is  plugged,  the  tamponing  material  will  prob- 
ably come  in  contact  with  the  bleeding  point  and  directly  close 
it;  but  if  merely  the  anterior  and  posterior  nares  be  occluded, 
then  the  blood  accumulates  in  the  included  passage,  and,  clotting, 
arrests  the  bleeding.  But  before  coagulation  occurs,  a  large 
amount  of  blood  is  poured  out,  which  seeks  vent,  and  may  pen- 
etrate the  sinuses  connected  with  the  nose.  It  has  been  seen  to 
pass  through  the  lachrymal  canal  and  appear  in  the  corner  of 
the  eye:  and  in  a  case  thus  treated  by  Crequy,  after  some  hours 


380  NOSE    AXD    NASAL    PASSAGES. 

the  blood  escaped  from  the  ear;  and  later  the  cheeks  and  eyelids 
became  swollen;  and  the  condition  became  so  perilous  that  the 
tampon  was  removed,  and  a  solution  of  a  salt  of  iron  was  injected 
into  the  nostrils,  and  thus  a  clot  "was  created  which  arrested  the 
htcmorrhage.  Should  the  anterior  and  posterior  plugging  be 
done  in  a  case  in  wliicli  the  bleeding  is  so  j^ersistent  as  in  the 
case  of  Cre'quy,  tiien,  after  the  posterior  nares  are  occluded,  a 
styptic  fluid  injected  in  front  might  arrest  the  bleeding,  or  cer- 
tainly insure  control,  if  the  anterior  nares  also  be  pklgged. 

The  author,  in  a  case  of  terrible  nasal  haemorrhage  in  a  leu- 
csemic  child,  controlled  the  bleeding  by  carotid  compression.  And 
this  compression,  which  is  best  done  digitally,  need  not  be  contin- 
uous. Pressure  made  for  ten  or  fifteen  minutes  usually  suffices 
to  arrest  the  bleeding;  and  when  the  hsemorrhage  reappears,  the 
pressure  must  be  repeated.  Such  compression  must  be  made  on 
the  vessel  where  it  lies  alongside  of  the  larynx,  just  prior  to  its 
bifurcation:  and  to  be  efiective,  the  work  must  be  done  by  an 
instructed  hand.  The  error  often  fallen  into  is,  in  prosing,  to  force 
the  artery  inwards  beneath  the  side  of  the  larynx.  When  the 
bleeding  is  arrested  by  tlie  compression,  the  pressure  may  gradually 
be  lessened,  and  finally  discontinued.  Here,  as  in  compression 
to  cure  aneurism,  the  flow  of  the  blood  through  the  vessel  should 
not  be  entirely  checked;  enough  should  be  permitted  to  pass  to 
form  an  occluding  clot. 

A  simple  method  to  arrest  nasal  bleeding  is  to  lift  and  main- 
tain the  arm  erect  on  the  affected  side.  The  manner  in  wliich 
this  acts  may  be  explained  as  follows:  The  heart,  to  propel  the 
blood  througli  the  vascular  circuit,  exerts  a  fixed  amount  of  force: 
now  if  one  arm,  and  still  more  if  botli  arms,  be  uplifted,  no  small 
amount  of  tliis  energy  will  be  used  in  moving  and  sustaining  the 
high  column  of  blood  in  the  erect  limbs:  and  this  ex[)enditure 
will  lessen  the  pressure  in  the  nasal  vessels,  and  tend  to  lessen  or 
arrest  haemorrhage  from  the  nose. 

Thus  a  French  surgeon  narrates  that  during  a  campaign  in 
the  north  of  Africa,  a  number  of  soldiers  who  were  seized  with 
Aasal  hsemorrhage  from  exposure  to  the  tropical  sun,  were  ordered 
to  lift  up  an  arm,  with  the  result  that  the  bleeding  was  arrested. 

X  method  akin  to  this  is  that  of  Bresger  of  Vienna,  who  in 
1883  advised  as  a  means  to  check  nasal  bleeding  that  the  patient 
stand  erect ;  such  position  would  lessen  pressure. 

Foreign  Bodies  in  the  Nasal  Passages. — Children  to  amuse 
themselves,  or  to  gratify  a  curiosity  to  explore  the  cavity  of  the 


FOREIGN    BODIES    IX    THE    NASAL    PASSAGES  381 

nose,  thrust  bodies  into  the  nostrils,  which  remain  and  partially 
obstruct  the  passage.  Examples  of  such  bodies  often  thus  toyed 
with  are  the  seeds  of  apples  and  cherries,  peas,  beans,  beads,  peb- 
bles and  other  small  bodies  used  as  playthings  by  the  child.  In 
swallowing,  fragments  of  food  sometimes  enter  and  lodge  in  the 
posterior  nares.  This  occurs  in  the  adult;  and,  as  a  rule,  intrud- 
ing material  is  dislodged  by  coughing. 

Foreign  bodies  may  lodge  in  any  portion  of  the  cavities,  yet 
the  most  usual  site  is  the  inferior  meatus,  xlt  first,  it  may  pro- 
duce but  slight  irritation;  yet  later  the  body  becomes  a  nucleus 
about  which  the  nasal  excreta  collect,  harden  and  enlarge  the 
body.  If  it  be  a  seed  which  can  germinate,  it  swells,  and,  as  in 
the  case  of  the  bean  seen  by  Boyer,  it  can  sprout.  In  his  case, 
the  bean,  having  sent  forth  a  dozen  roots,  was  imbedded  in  a  mass 
of  hardened  matter,  and  had  been  mistaken  for  a  polypus.  Also 
an  inorganic  body  may  become  coated  with  hardened  saline 
material,  until  it  reaches  such  dimensions  as  to  crowd  on  and 
irritate  the  adjacent  walls.  Such  body  is  sponge-like  and  easily 
broken,  and  sometimes  presents  irregularities  of  surface  similar 
to  a  mulberry  calculus  of  the  bladder.  In  other  cases  it  has  been 
found  of  stone-like  hardness. 

Again,  concretions  of  mineral  matter  in  which  no  jDreexistent 
nucleus  can  be  discovered,  occur  in  tlie  nasal  passages.  This 
body,  named  rhinolith,  is  a  calcareous  compound,  and  is  composed 
of  carbonate  and  phosphate  of  lime.  Its  origin  has  been 
referred  to  an  inflamed  condition  of  the  pituitary  membrane; 
others  refer  it  to  an  affection  of  the  lachrymal  gland.  A  gouty 
diathesis  has  been  assigned  as  a  cause.  Such  petrifaction  is  an 
occasional  accompaniment  of  ozsena,  in  which  disintegrated 
nasal  material  forms  crust-like  concretions,  which  collect  and 
adhere  to  the  irregular  recesses  of  the  nasal  fossse.  The  rhinolith 
may  appear  single  or  multiple.  When  divided  by  a  saw,  they 
present  concentric  layers,  or  there  may  be  a  central  cavity  con- 
taining fetid  matter. 

"When  the  rhinolith  attains  considerable  size,  it  becomes  a 
constant  irritant  and  causes  swelling,  and  sometimes  a  sanious 
or  sanguinolent  discharge.  The  condition  is  similar  to  that 
caused  by  a  foreign  body  which  has  lodged  a  long  time  in  the 
nasal  fossee.  The  body  can  become  embedded  in  the  swollen 
mucous  membrane,  so  that  the  latter  nearly  covers  the  concretion. 
About  the  site  of  it  one  finds  masses  of  ill-smelling,  cheese-like 
matter. 


382  NOSE    AND    NASAL    PASSAGES. 

It  is  evident  that  both  a  rhinolitli,  as  well  as  a  foreign  body 
lodged  in  the  nose,  can  occasion  great  inconvenience  in  causing 
foul  breath  and  an  intolerably  offensive  discharge.  The  irrita- 
tion may  extend  to  the  eyes,  and,  besides  conjunctival  redness, 
there  may  be  flowing  of  tears. 

Yet,  despite  these  and  other  indications  pointing  to  the  pres- 
ence of  a  foreign  body  in  the  nasal  passages,  from  the  neglect  of 
careful  examination  of  the  cavity,  the  condition  has  been  mis- 
taken for  some  more  grave  affection.  More  than  once  a  severe 
operation  has  been  arrested  midway,  which  would  not  have  been 
commenced  had  there  previously  been  made  a  careful  examina- 
tion with  speculum  and  probe.  The  writer  was  the  intervener 
once  in  a  case  in  which  the  patient  was  saved  from  a  painful 
operation  that  was  on  the  eve  of  being  performed ;  a  probe 
introduced  found  a  movable  foreign  body,  which,  being  removed, 
proved  to  be  a  cherry-seed  incrusted  with  calcareous  matter. 
Several  cases  are  recorded  in  which  the  rhinolith  was  mistaken 
for  necrosed  bone. 

Such  bodies  are  commonly  easily  removed  by  means  of  prop- 
erly constructed  forceps.  Durham  uses  a  pair  of  forceps  of  which 
the  blades  can  be  separated  and  introduced  singly,  and  then  locked. 
A  forceps  with  small  blades  which  are  toothed  answers  the  pur- 
pose well.  The  precaution  must  be  taken  not  to  force  the  body 
backwards  into  the  pharynx,  since  it  might  drop  into  the  wind- 
pipe and  cause  strangulation.  After  the  removal,  the  passage 
should  be  irrigated  for  a  time  with  some  anti-septic  fluid. 

Parasites  in  the  Nasal  Po-s-sa^cs.— Frequently  in  the  tropics, 
and  sometimes  in  the  temperate  zone,  parasites  have  Ijeen  known 
to  enter  the  nasal  passages,  and  deposit  larvae,  which  develop 
there.  This  parasite  is  a  species  of  insect,  and  from  its  habit  is 
named  Lucilia  hominivora.  It  probably  lays  its  eggs  in  the 
entrance  of  the  nares;  and  the  eggs  are  afterwards  drawn 
inwards  by  inspiratory  efforts,  and  lodged  in  the  deeper  recesses 
of  the  nose.  As  the  in.sect  develops,  it  causes  a  stinging  or 
boring  pain,  also  epistaxis.  If  undisturbed,  the  insects  continue 
their  ravages,  in  which  the  soft  parts  ulcerate,  and  tlie  bones  are 
perforated.  Later,  the  face  is  opened,  and  the  disintegrated 
structures  teem  witli  moving  worms.  This  hominivorous  parasite 
has  been  known  to  perforate  the  base  of  the  skull,  and,  having 
entered  the  cavity,  caused  death  by  meningitis. 

As  soon  as  such  trouble  is  suspected,  the  enemy  should  be 
vigorously  attacked   by   local  remedies.     Among  the  most  effi- 


OZ.EXA,    OR    XASAL    CATARRH.  383 

cieiit  means  at  our  control  is  turpentine,  which  is  swiftly  fatal  to 
insect  life.  In  solution,  or  in  its  pure  state,  this  agent  should  be 
injected  into  the  affected  cavity.  Other  germicidal  solutions  may 
be  used;  for  example:  chlorinated  or  sublimated  solutions. 
The  fumes  of  tobacco,  arsenic,  or  chloroform  may  also  be  used.  The 
frontal  sinus  has  been  trephined,  and  the  germicidal  solution 
thrown  through  the  opening  into  and  through  the  nasal  passages. 
Ozsena,  or  Nasal  Catarrh. — The  essential  idea  implied  by  the 
term  ozpena  is  afoul  odor;  and  since  fetor  of  the  breath  is  the 
prominent  characteristic  of  nasal  catarrh,  the  terms  ozsena  and 
nasal  catarrh  are  equivalent  terms.  The  European  writers  more 
often  use  the  name  ozsena,  while  the  American  writers  often er 
employ  the  name  nasal  catarrh.  The  name  ozsena  will  be  used 
by  the  writer,  inasmuch  as  it  more  definitely  specifies  the  most 
offensive  feature  of  the  disease;  catarrh,  or  descending  discharge, 
only  occasionally  offends  the  sight  of  others,  while  the  foul  breath 
of  the  patient  is  an  unending  annoyance  to  those  within  its 
reach. 

Ozsena,  then,  may  be  defined  to  be  a  disease  of  the  nose  in 
which  there  is  a  diseased  condition  of  the  inner  surface  of  tlie 
nasal  passages,  whence  ill  smelling  matter  is  excreted;  and  this 
material  may  be  profuse  in  amount,  or  so  small  in  quantity  as 
scarcely  to  be  discoverable.  And  this  difference  in  the  amount 
of  tlie  excretion  led  Hedenus,  writing  on  the  subject  in  1861,  to 
make  two  species:  one  in  which  there  is  a  discharge,  and  another 
with  no  discharge;  and  the  former  may  be  of  scrofulous,  herpetic, 
syphilitic  or  mercurial  origin. 

In  1863  Trousseau,  writing  on  ozsena,  finds  that  ill  breath 
may  arise  from  causes  outside  of  the  nasal  disease:  it  may  arise 
from  the  mouth,  teeth,  throat,  disease  in  the  oesophagus,  and  he 
might  have  added,  disease  of  the  lungs.  Some  persons,  again, 
have  ill  smelling  excretions,  of  which  it  is  difficult  to  determine 
the  caase;  and  such  cases  are  sometimes  incurable. 

To  determine  whether  the  fetor  proceeds  from  the  nose  or  the 
mouth,  Trousseau  directs  to  alternately  close  the  one  and  the 
other;  by  thus  doing  the  true  source  of  the  odor  will  be  discov- 
ered. An  error  might,  how^ever,  be  made  in  cases  in  which  fetid 
matter  has  fallen  into  the  choanse,  or  space  which  is  common  to 
the  mouth  and  nose. 

Fortunate  for  the  patient  of  ozsena,  his  fetid  breath  only  dis- 
turbs others ;  and  only  by  others  is  he  reminded  of  his  unfortu- 
nate condition.     A  fetid  odor  may  be  generated  by  a  healthy 


384  NOSE    AND    NASAL    PASSAGES. 

secretion  when  this  remaius  too  long  in  contact  with  its  generat- 
ing surface.  But  if  the  surface  is  unhealthy,  then  the  jnatter 
excreted  is  offensive  as  soon  as  it  is  found. 

Ozaena  is  commonly  associated  with  some  constitutional 
cachexy ;  such  cachexy  may  be  scrofula,  scorbutus,  tuberculosis 
and  syphilis;  a  scrofulous  or  syphilitic  origin  is  oftenest  met 
with.  It  may  be  associated  with  some  cutaneous  disease,  as  lupus, 
herpes;  or  an  exanthema,  as  scarlatina,  may  be  referred  to  as  tlie 
origin. 

In  the  general  constitutional  disease,  or  the  cutaneous  causal 
affection,  the  mucous  membrane,  as  well  as  the  subjacent  osseous 
and  cartilaginous  structures,  become  affected.  Primarily,  the 
mucous  membrane  is  swollen;  and  the  localization  of  the  dyscra.sy 
here  is  favored  by  the  numerous  acinous  glands  seated  in  the 
membrane.  This  swollen  stage  is  nearly  odorless,  and  succeeded 
by  an  atrophic  one  in  which  the  fetor  is  present.  In  the  atropljic 
condition  the  thick  tenaceous  secretion  is  retained  and  decomposes. 
Also,  if  the  profuse  discharge  from  the  hypertrophic  form  remains, 
dries  and  adheres,  crust-like,  to  the  surface,  a  fetor  may  arise 
from  this  desiccated  matter. 

According  to  Max  Schaefer,  of  Bremen,  scrofulous  ozaena 
occurs  between  the  riinth  and  twelfth  years  of  age,  and  begins 
with  a  snuffling  and  nasal  discharge.  The  membrane  here  is 
swollen;  but  the  atrophic  form  occurs  in  older  persons. 

At  a  medical  congress  in  London,  in  1881,  oziena  was  the 
subject  of  discussion.  Frankel  claimed  that  it  is  associated  with 
a  chronic  catarrh ;  and  there  is  atrophy  of  the  mucous  membrane 
to  a  greater  or  less  degree.  The  ill  odor  is  from  the  stagnant 
excreta. 

Fournier,  referring  the  origin  of  ozsena  to  syphilitic,  dipli- 
theritic,  catarrhal  or  scrofulous  disease,  finds  that  it  may  be  moist 
or  dry  in  character. 

AVatson  finds  ozaena  associated  with  lupus  and  chronic  eczema. 

Martin,  of  Paris,  finds  an  ulcerative  and  a  non-ulcerative 
form ;  in  the  latter  the  periosteum  and  bones  do  not  become 
affected;  and  he  and  Zaufal  refer  this  species  of  ozjena  to  a 
preternatural  width  of  the  nostrils.  They  claim  that  this  width 
of  nostrils  depends  on  a  cessation  of  growth  of  the  inferior  turbi- 
nated bones,  in  which  the  middle  turbinated  bone  is  also  impli- 
cated. In  this  malformed  condition  of  the  nose,  atrophy  with 
catarrhal  discharge  ensues. 

Hedenus  saw  cases  of  ozaena  in  which  the  fetid  breath  ap- 


OZiENA,    OR    NASAL    CATARRH.  385 

peared  and  continued  only  during  the  time  of  the  menstrual  flux. 

Hence,  as  appears  from  the  preceding,  authors  agree  in  opinion 
thatozsena  is  dependent  on  some  general  or  constitutional  disease, 
and  that  the  nasal  affection  is  only  a  local  manifestation  of  the 
same.  This  local  trouble  may  be  limited  to  a  simple  swelling  of 
the  lining  membrane,  and,  as  a  result  of  this  hypersemic  condi- 
tion, the  mucous  glands  become  abnormally  active;  or  the  disease 
may  not  thus  be  limited,  but  may  reach  to  and  attack  the  sub- 
jacent bones.  The  osseous  invasion  may  be  caused  by  gumma- 
tous or  other  neoplastic  development,  which  interferes  with  the 
proper  vascular  supply  of  the  parts;  or  the  nutrient  supply  can 
be  obstructed  by  embolic  or  thrombic  closure  of  the  minute 
vessels.  The  dry  atrophy  of  the  membrane,  before  mentioned, 
may  be  thus  caused.  Inveterate  duration  of  the  disease,  and 
rebellious  obstinacy  to  resist  treatment,  characterize  those  cases  in 
which  the  turbinated  bones  and  the  septum  have  become  affected. 
And  when  this  stage  is  reached,  the  sense  of  smell  is  greatly 
impaired.  The  delicate  structure  of  the  terminal  filaments  of 
the  olfactory  nerve  are  the  subjects  of  lesion,  which  sometimes 
proceeds  to  the  partial  loss  or  total  extinction  of  the  sense  of 
smell;  and  as  this  impairs  thegustative  sense,  it  results  that  the 
subject  of  oz8ena  becomes  maimed,  as  to  two  of  his  important 
special  senses.  Also,  the  bones  when  once  lost  are  never  restored; 
hence  ozsena,  with  necrosis  of  the  interior  bones,  entails  perma- 
nent mutilation  of  the  interior  architecture  of  the  nose;  and,  in 
some  cases,  the  collateral  constitutional  disease  destroys  the  ex- 
ternal skeleton  of  the  organ,  and  ends  in  the  sinking  of  the  nasal 
arch,  and  leaving  one  of  the  most  offensive  of  disfiguring  deform- 
ities, viz.,  the  saddle-seat  nose.  With  these  possible  eventualities, 
especially  if  the  affection  arise  from  constitutional  disease,  ozsena 
demands  earnest  care  on  the  part  of  the  surgeon. 

Treatment. — This  will  vary  according  to  the  stage  to  which  the 
disease  has  proceeded,  as  well  as  according  to  the  character  of  the 
causal  constitutional  disease :  conditions  demanding  varied  local 
and  general  treatment.  Where  the  ozsena  has  arisen  from  syph- 
ilis, the  patient  should  receive  such  varied  care,  viz.,  mercur}^ 
and  iodine,  with  a  predominance  of  the  latter;  and,  locally,  the 
parts  should  be  treated  with  astringent  and  alterative  compounds, 
of  which  mention  will  presently  be  made.  In  all  cases  scrupulous 
care  must  be  used  to  remove  the  nasal  excretions;  and  this  may 
be  done  by  resorting  to  Weber's  procedure,  in  which  the  fluid, 
siphon-like,  is  caused  to  make  the  circuit  of  the  nasal  passages. 


386  NOSE    AND    NASAL    PASSAGES. 

And  the  fluid  thus  used  should  be  warm  water,  to  which  is  added 
the  agent  designed  to  act  topically. 

If  the  oza?na  occur  in  a  tubercular  or  scrofulous  subject,  anti- 
scrofulous  remedies  must  be  administered,  viz.,  iodine  and  cod 
liver  oil.  If  the  affection  of  the  nasal  surface  is  confined  to  the 
mucous  membrane,  and  consists  of  a  swollen  state  of  the  same, 
linear  thermal  cauterization  should  be  resorted  to.  This  may 
be  done  with  the  wire  loop  of  the  galvano-cautery,  which,  for  a 
moment,  is  caused  to  touch  in  lines  the  affected  surface ;  or,  in 
absence  of  the  thermal  appliance,  a  simple  one  may  be  extem- 
porized of  a  steel  pin  fixed  on  a  cork  for  a  handle,  of  which  one 
end,  heated  in  a  lamp,  may  do  the  w^ork  of  linear  cauterization. 
Thus  fine  linear  sloughs  are  produced,  and  the  heat,  coagulating 
the  blood  in  the  subjacent  vessels,  lessens  the  nutritive  supply, 
and  thus  reduction  of  structure  is  accomplished.  In  place  of 
fire,  a  potential  caustic  may  be  used,  viz.,  with  a  pencil  of  nitrate 
of  silver,  or  of  fused  potassa;  one  may  touch  and  destroy'  small 
sections  of  surface,  and  thus  effect  structural  retrenchment. 

As  local  treatment  advised  by  different  authorities,  the  follow- 
ing may  be  cited:  Hedenus  used  creosote  both  internally  and 
externally.  Pulverized  charcoal,  to  wliicli  some  aromatic  is 
added,  as  the  oil  of  anise,  bergamot,  etc.,  may  be  used  as  a  snuff. 
Tincture  of  myrrh  with  infusion  of  bark  may  be  used  locally. 
Where  the  local  application  caused  too  much  discharge,  Hedenus 
added  alum  to  it.  As  errhine  remedies,  Trousseau  advises  the 
u.se  of  subnitrate  of  bismuth,  chlorate  of  potash,  and  especially 
the  red  precipitate  of  mercury.  The  nasal  passage  should  be 
prepared  for  the  use  of  these  remedies  by  previous  irrigation. 
As  nasal  injection.  Trousseau  uses  a  solution  of  nitrate  of  silver, 
corrosive  sublimate  or  sulphate  of  copper.  As  internal  medica- 
tion he  uses  iodine,  cod  liver  oil  and  the  preparations  of  arsenic. 
Schaefer  cleanses  the  passages  with  a  syringe,  and  cauterizes 
thickened  .surfaces;  and,  for  use  by  insufflation,  he  employs. the 
following  powder: — 

1^.    Argeiiti  Xitratis gr.  i  ad  x 

Talci 9ijss 

Mi  see. 
Or, 
5t.    Sodii  Benzoatis gr.  x 

Talci gr.  50 

Misce. 


OZ^NA,    OR    NASAL    CATARRH.  387 

Insufflation  can  also  be  done  with  boric  acid,  alum,  or 
iodoform.  Frankel  cauterizes  with  the  hot  iron.  Fournier,  as 
local  means,  uses  the  decoction  of  althaea  and  that  of  poppies. 
The  crusts  of  concrete  matter  must  be  removed,  and  the  surface 
touched  with  nitrate  of  silver,  carbolic  acid  or  tincture  of  iodine- 
In  the  dry  form  with  constitutional  cachexy,  Fournier  advises 
arsenical  baths,  and  he  gives  internally  arsenic  and  the  bicarbonate 
of  soda.  In  the  moist  constitutional  form  be  uses  sulphur  baths 
and  internally  iodine,  iron  and  cod  liver  oil.  He  removes  the 
crusts  and  injects  a  two  per  cent  solution  of  salicylate  of  sodium. 
Fournier  cauterizes  the  ulcerated  surface  with  nitrate  of  silver. 
The  treatment  must  often  be  continued  for  a  period  of  two  years. 
Relapses  are  frequent,  so  that  treatment  must  often  be  resumed 
again.  AYatson  uses  iodoform  bougies,  and  lets  the  patient  snuff 
bismuth  in  powder.  Internally  he  administers  iron,  arsenic,  cod 
liver  oil,  iodine,  copaiba  and  mineral  acids.  Gottstein,  after 
removing  the  crusts  that  form  in  chronic  cases,  introduces  tam- 
pons of  cotton  into  the  nostrils,  and  he  limits  his  treatment 
chiefly  to  this  simple  work. 

As  ozsena  may,  according  to  Zauful  and  Hartmann,  arise  from 
too  great  width  of  the  nostrils,  it  is  probable  that  in  such  cases 
relief  might  be  obtained  by  lessening  the  entrance  of  the  nares. 
To  do  this,  a  wedge-shaped  portion  might  be  excised  from  the 
posterior  part  of  the  nostril,  viz.,  where  the  wall  is  continuous 
with  the  upper  lip.  The  wound  thus  made  is  to  be  closed  by  a 
deep  metallic  suture.  Such  an  operation,  besides  lessening  the 
orifice,  would  improve  the  form  of  the  nose;  it  would  overcome 
in  some  degree  the  unsightly  flaring  of  the  part. 

In  the  forms  of  ozsena  mentioned  the  disease  was  limited  to 
the  pituitary  membrane;  it  may  advance  further,  and  attack  the 
bones  of  the  nasal  labyrinth,  and  this  is  not  unfrequent  in  the 
subject  of  tertiary  syphilis.  Also  in  patients  of  scrofula  in  whom 
there  is  an  element  of  congenital  syphilis,  there  is  often  an  affec- 
tion of  the  nasal  passages,  which  finally  attacks  the  turbinated 
bones  and  the  septum.  The  concealed  site  of  these  bones  permits 
the  affection  to  lurk  in  them  for  a  long  time  before  the  full  extent 
of  the  disease  is  realized  by  the  patient  or  suspected  by  the  phy- 
sician. The  fetor  from  the  necrosing  structures  finally  announces 
the  nature  and  advanced  stage  of  the  disease.  The  course  of 
such  a  case,  if  its  stages  be  enumerated  in  their  consecutive 
appearance,  is  primarily  a  congestion  of  the  mucous  membrane 
which  lines  the   nasal  cavity;  this   congestion  arises  from  the 


388  NOSE    AND    NASAL    PASSAGES. 

return  of  the  blood  being  ini])cdecl  by  minute  gummy  or  connec- 
tive tissue  growths,  developed  by  constitutional  disease.  The 
bone,  deprived  of  a  regular  supply  of  aerated  blood,  dies,  and  the 
investing  membrane  dies  also  at  points,  and  this  constitutes  tiie 
secondary  or  destructive  stage.  There  is  now  concurrent  necrosis 
and  ulceration.  The  tenuity  of  the  bones  is  such  that  dentli  of 
surface  involves  death  in  totality.  For  the  ulceration  attacks 
both  sides  of  the  paper-like  bone,  wlien  the  arrested  or  dis- 
turbed circulation  becomes  inadequate  to  maintain  vitality. 
This  process  continuing,  a  large  ])ortion  of  a  turbinated  bone,  or 
a  section  of  the  long  partition,  necroses,  becomes  loosened  and 
detached  from  the  remaining  parts,  and,  like  a  foreign  body  in 
the  passage,  moves  during  the  act  of  clearing  the  nostrils.  The 
necrosed  bone  when  loosened  a[)pears  at  the  anterior  or  posterior 
outlet,  most  frequently,  at  one  nostril  in  front;  and  this  period  of 
elimination,  though  it  is  the  concluding  stage  of  the  worst  form 
of  oziena,  is  often  prolonged  for  an  indelinite  period:  first,  a  por- 
tion of  the  vomer,  and,  later,  its  entirety,  are  separated  and  thrown 
out.  Meantime  the  turbinated  bones,  one  or  all  of  them,  and 
the  perpendicular  plate  of  the  ethmoid,  die  and  are  eliminated; 
in  brief,  the  architectural  structure  of  the  nose  falls  piece  by  piece 
until  there  remains  little  else  than  the  superior  arch  formed  by 
the  nasal  bones;  and  even  these  occasionally  share  in  the  ruin, 
and,  sinking,  the  patient's  face  is  marred  with  the  revolting  deform- 
ity of  a  sunken  nose:  a  saddle-seat  on  which  the  fiend  of  impure 
venery  mounts  and  announces  himself  to  every  observer. 

The  treatment  of  this  destructive  form  of  ozEena,  if  wary,  fore- 
seeing and  comprehensive,  will,  at  an  early  period,  apply  the  ax 
at  the  root  of  the  causal  tree,  in  the  form  of  remedies  which  will 
arrest,  if  not  extinguish,  the  constitutional  cachexy.  If,  however, 
the  surgeon  only  sees  the  case  at  the  second  stage,  when  necrosis 
has  commenced,  an  effort  must  be  made  to  stay  or  limit  the 
destruction  of  the  bones.  Nasal  irrigation  to  remove  the  septic 
excreta  must  be  industriously  done;  and  for  this  purpose  alkaline 
solutions  should  be  used,  viz.,  a  .solution  of  carbonate  of  potassium, 
in  the  j)roportion  of  five  grains  to  the  ounce;  or  Aqua  calcis  may 
be  used.  A  solution  of  chloride  of  sodium,  or  of  borax,  may  be 
used,  yet  the  jiurely  alkaline  solutions,  which  as  chemical  agents 
are  solvents  of  albuminous  or  fibrinous  matters,  will  be  more 
effective  in  dissolving  and  removing  excreta  which  are  cognate 
to  such  material  in  composition.  To  chock  osseous  decay,  irriga- 
tion may  be  done  with   iodized  .solutions;  for  example,  iodide  of 


OZ.EXA,    OR    XASAL    CATARRH.  389 

potassium  in  the  proportion  of  half  a  drachm  to  an  ounce  of 
water.  Or  a  drachm  of  tincture  of  iodine  to  an  ounce  of  water 
might  be  injected  into  the  nasal  passage.  In  case  the  necrosis 
has  involved  but  a  limited  portion  of  bone,  for  instance,  a  section 
of  the  vomer,  the  query  arises:  Should  the  dead  portion  be  removed 
at  once,  or  should  one  delay  until  the  sequestrum  is  wholly 
detached? — a  question  not  promptly  to  be  answered,  according 
to  the  writer's  experience.  The  observation  of  cases  in  which  the 
dead  bone  was  removed  early,  and  of  others  in  which  removal 
was  delayed,  inclines  the  writer  to  advise  late  removal  as  the  bet- 
ter practice ;  for  in  the  work  of  extracting  the  dead  bone  before 
its  detachment,  the  adjacent  bone,  which  is  but  slightly  affected, 
may  be  disturbed  and  its  death  favored.  Hence  the  more  con- 
servative method  is  to  wait  until  the  sequestrum  is  freely  mov- 
able, and  then  remove  it  with  a  pair  of  forceps.  If  the  osseous 
fragment  is  too  large  to  emerge  from  the  nostril,  as  sometimes 
is  the  case,  then  it  should  be  divided  with  cutting  forceps. 

"When  the  osseous  septum  and  the  turbinated  bones  are  lost, 
there  is  no  reparative  power  in  the  tissues  which  invest  them  to 
repair  the  breach;  the  partial  or  complete  destruction  of  the  lin- 
ing periosteum  and  the  ulcerated  and  diseased  state  of  the  pit- 
uitary membrane  forbid  any  hope  of  such  repair;  the  work  of 
devastation  has  permanently  ruined  the  interior  of  the  nose,  and 
with  such  ruin  the  sense  of  olfaction  partially  or  comjdetely 
vanishes. 

If  tlie  necrosis  should  invade  a  nasal  bone  on  its  inferior  sur- 
face, the  osseous  destruction  may  proceed  until  tlie  bone  is  per- 
forated or  is  so  weakened  that  it  cannot  maintain  its  position 
longer;  it  sinks,  and  lets  the  overlying  soft  parts  sink  inwards. 
This  sinking  may  be  on  one  side;  or,  both  sides  falling,  the  lobule 
of  the  nose  is  tilted  upwards,  and  the  complete  saddle-seat  nose 
is  present.  The  deviation,  both  of  side  and  point  of  nose,  may 
be  greater  towards  one  side. 

If  the  patient  be  treated  properly,  constitutionally  and  locally, 
the  event  here  described  may  be  averted;  the  weapons  are  mercury 
internally  and  iodine  internally  and  externally,  with  nasal  irriga- 
tion. Iodine,  used  locally, is  the  most  efficient  remedy.  To  use  this 
apply  the  tincture  of  iodine  on  the  inside  and  iodine  ointment 
on  the  outside.  Thus  the  minute  gummatous  and  scrofulous 
neoplasms  which  may  exist  in  the  mucous  membrane,  or  the 
inner  or  outer  periosteal  lining,  will  be  caused  to  recede,  and  the 
vitalilv  of  the  bone  n:iaintained.     This  absorbent,  or  better  stvled 


390  NOSE    AND    NASAL    PASSAGES. 

conservative,  action  of  iodine  has  been  verified  by  the  writer  in  a 
few  cases.  If,  however,  through  neglect  of  treatment,  the  necro- 
sis be  allowed  to  proceed,  the  dead  hone  is  eliminated  piecemeal, 
rather  than  in  entirety;  so  that  portions  of  the  nasal  bones 
remain,  especially  the  articulating  borders.  Occasionally  the 
skin  is  perforated,  and  the  sequestrum  thus  escapes,  and  a  scar 
results.  In  the  majority  of  cases,  however,  the  elimination  of 
the  dead  bone  is  on  the  inside  tlirough  a.  breach  in  the  ulcerated 
mucous  membrane;  and  the  avoidance  of  a  scar,  which  then 
results,  renders  this  mode  of  ending  preferable  to  the  other. 

In  operations  on  the  face  and  mouth,  in  which  blood  may 
pass  into  the  nares  and  thence  into  the  pharynx,  Verneuil  advises 
as  a  preliminary  to  tampon  the  posterior  nares  by  the  aid  of 
Bellocq's  cannla;  after  such  ]>reliminary  plugging,  the  patient  can 
be  anaesthetized,  and  the  operation  more  safely  done. 


CHAPTER  X. 


MAXILLARY   SINUS,    OR    ANTRUM    OF    HIGHMORE. 

Of  the  three  accessory  cavities,  which  communicate  with  the 
nasal  fossse,  the  largest  is  the  maxillary  sinus,  or  antrum  of 
Highmore.  This  exists  at  birth,  while  the  frontal  sinus  develops 
post-natally.  In  the  adult  this  large  air-cell  is  prismoidal  in 
figure,  and  has  four  bounding  walls.  It  may  be  compared  to  an 
irregular  triangular  pyramid,  the  base  of  which,  lies  upwards, 
and  is  formed  by  the  floor  of  the  orbit.  This  wall  is  traversed 
from  behind  forwards  by  the  continuation  of  the  superior  max- 
illary nerve.  Of  the  three  vertical  walls,  the  internal  one 
separates  the  antrum  from  the  nasal  fossse;  a  second  or  front 
wall  lies  behind  the  cheek,  and  looks  for\tards  and  outwards;  the 
remaining  wall  looks  backwards  and  outwards.  These  three 
upright  walls  converge  from  above  downwards,  so  that  the- inferior 
floor  is  very  small  when  compared  with  the  upper  one. 

There  are,  as  a  rule,  two  openings  from  the  middle  meatus  of 
the  nasal  fossse  into  the  maxillary  sinus.  Near  the  middle  point 
of  this  meatus  exists,  usually,  an  opening  which  leads  directly 
into  the  antrum;  but  more  careful  observation  has  found  that 
this  orifice  may  be  absent,  or,  at  least,  so  occluded  by  mucous 
membrane  as  to  prevent  the  passage  of  fluids.  But  near  the 
anterior  end  of  the  middle  meatus  there  lies  the  infundibuliform 
opening  of  the  frontal  sinus  into  the  nasal  passage,  and  if  the 
outer  wall  of  this  funnel-shaped  passage  be  examined,  there  will 
be  found  an  opening  into  the  antrum ;  so  that  if  a  fluid  be  injected 
from  the  frontal  sinus,  some  of  it  will  pass  into  the  antrum. 
This  normally  duplicated  communication  between  the  nasal  fossae 
and  the  antrum  gives  additional  security  against  the  accumula- 
tion of  fluid  material  in  the  antrum. 

As  seen,  there  are  three  sides  in  which  openings  can  be  made, 
and  a  communication  established  with  the  cavity  of  the  antrum; 
viz.,  through  the  inner  wall,  through  the  anterior  one,  and  thirdly 
through  the  underlying  alveolar  process.     The  opening  through 

(391) 


o02  MAXir.LARY    SINUS,    OR    ANTRUM    OF    HIGHMORE. 

(he  inner  wall  would  be  difficult  to  make,  and,  when  formed, 
would  be  too  indirect  for  use  by  the  surgeon.  An  opening  through 
the  alveolar  process  may  be  made  through  the  site  of  a  molar 
tooth ;  yet  this  rc(|uires  tlie  extraction  and  sacrifice  of  an  important 
tooth,  viz.,  the  second  molar.  As  most  patients  Avould,  like  Don 
Quixote,  part  with  sucli  a  tooth  as  sadly  as  tlicy  would  with  a  near 
friend,  hence  there  are  earnest  objections  to  this  site  for  an  open- 
ing into  the  antrum,  and,  besides,  such  opening  is  apt  to  remain 
open.  A  third  route  by  which  tlie  antrum  can  be  entered  is 
through  the  anterior  wall,  which  is  thin,  and,  if  opened,  it  can  be 
closed  without  difficulty. 

We  will  next  proceed  to  consider  the  surgical  affections  of  the 
antrum,  and  will  connnence  with  fracture. 

Fracture  of  the  anterior  wall  is  not  an  unfrequent  occurrence, 
and  this  may  be  subcutaneous  or  complicated  with  an  open 
wound.  The  thinness  of  the  anterior  wall,  and  its  exposed  posi- 
tion in  the  face,  render  it  lial)le  to  fracture.  And  within  the 
writer's  observation  a  number  of  such  cases  have  been  observed, 
in  whicli  the  causal  agency  was  a  kick  of  a  horse,  or  a  blow  with  a 
strong  fist.  If  the  violence  be  not  great,  then  the  soft  parts  are  not 
opened,  but  the  wall  of  the  maxillary  sinus  is  broken  and  driven 
inwards,  and  thus  a  depression  is  made  in  the  face,  below  the  eye, 
and  outside  of  the  nose.  And  the  depressed  bone  will  remain  in 
its  new  position  unless  restored  to  place  by  surgical  assist  mce. 
The  rule  has  been,  if  an  attempt  was  made  to  reduce  to  normal 
form,  to  attempt  this  by  an  incision  in  the  cheek,  and  through 
this  to  elevate.  As  this  must  leave  a  prominent  scar,  the  patient 
has  commonly  jireferred  to  retain  the  sunken  place  in  his  cheek 
rather  than  to  exchange  it  for  an  unsightly  cicatrix.  In  place  of 
this  method,  the  author  proposes  a  less  deforming  one,  as  follows: 
In  the  cul-de-sac  between  the  alveolar  jirocess  and  the  lip,  make 
an  opening  close  to  the  bone  until  the  canine  fossa  on  the  upper 
jaw  is  reached,  and,  having  exposed  this,  perforate  the  wall  with 
a  small  trephine,  or  a  carved  chisel,  and  through  this  opening 
introduce  an  elevator  and  restore  to  normal  position  the  sunken 
wall;  and,  thus  outlifted,  the  wall  would  remain  in  normal  posi- 
tion. The  opening  which  the  surgeon  has  made  would  soon 
permanently  close. 

A  more  severe  injury  is  that  in  whicli  there  is  an  open  wound 
to  the  fracture,  and  in  such  case,  there  may  be  a  number  of  frag- 
ments, some  of  which  may  lie  in  the  antrum,  and  others  may 
hang  to  shreds  of  the  torn  soft  parts;  in  fact,  there  are  present 


ABSCESS    OF    THE    MAXILLARY    SINUS.  393 

all  the  elements  of  a  severe  compound  fracture.  The  treatment 
here  will  commence  with  the  removal  of  fragments  which  are 
wholly  separated  from  tlie  soft  parts,  and  the  restoration  to  place 
of  fragments  which  are  adherent  to  the  lacerated  soft  parts. 
Fragments,  which  are  wholly  loose  and  have  no  vascular  connec- 
tion remaining,  should  be  removed,  for  if  left,  they  would  act  as 
foreign  bodies,  which  would  prevent  healing  of  the  wound.  But 
fragments  of  bone  that  are  adherent  to  flaps  of  the  torn  cheek, 
which  will  maintain  the  bone  alive,  must  be  preserved,  since 
their  preservation  will  materially  lessen  the  scarring  consequent 
on  such  open  fracture.  The  irregular  edges  of  these  usually  need 
not  be  trimmed,  but  if  they  have  a  fringe-like  border,  which 
floats  in  the  fluid  used  for  cleansing  the  wound,  this  edge  should 
be  trimmed  off,  and  the  fragments  or  flaps  should  be  restored  to 
site,  and  fixed  by  sutures,  which  should  first  connect  opposite 
angles  or  opposite  free  borders;  and  after  this,  suturing  should 
proceed  towards  the  base  of  the  flaps  or  beginning  of  the  borders. 
If  thus  united,  the  torn  parts  will  lie  in  their  natural  position. 
The  wound  should  be  dressed  with  lint  moistened  with  an  alco- 
holic sublimated  solution.  The  healing  occurs  rapidly,  and  often 
with  less  scarring  than  was  expected. 

An  occasional  accompaniment  of  fractures  of  the  walls  of  the 
antrum  is  the  passage  of  air  into  the  adjacent  soft  ])arts  of  the 
face.  This  may  arise  during  an  expiratory  effort,  in  which,  the 
mouth  and  nose  being  closed,  the  air  is  forced  into  the  wounded 
soft  parts.  Such  emphysema  will  be  the  cause  of  more  mental 
.than  physical  trouble  to  the  patient;  without  treatment  it  will 
vanish  in  a  few  days;  probably  much  of  it  returns  to  the  nasal 
passages,  through  contraction  of  the  containing  soft  parts.  If 
absorbed,  as  sometimes  stated,  would  not  its  presence  in  the  vessels 
occasion  serious  trouble? 

Gunshot  missiles,  as  balls  of  medium  calibre,  have  entered 
and  found  permanent  lodgment  in  the  maxillary  sinus;  such 
intruding  body  has  been  tolerated  in  this  recess  for  an  indefinite 
period,  causing  but  little  or  no  inconvenience.  As  such  missile, 
if  even  slightly  movable,  must  irritate  the  containing  cavity, 
its  removal  is  indicated.  This  extraction  can  be  done  by  detach- 
ing the  soft  parts  from  the  canine  fossa,  and  trephining  at  that 
point. 

Abscess  of  the  Maxillary  Sinus. — The  lining  mucous  membrane 
of  the  antrum  may  become  inflamed  and  pus  or  an  ichorous  fluid 
be  generated  in  the  cavity.  As  exciting  cause  of  the  inflamma- 
26 


394  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGHMOKE. 

tioii  may  be  an  eruptive  disease,  as  scarlatina  or  other  disease 
accompanied  by  embolic  processes.  A  frequent  cause  is  dental 
caries,  in  which  the  root  of  a  tooth  near  the  antrum  becomes 
affected.  As  is  known,  the  roots  of  the  first  and  second  molar 
teeth  often  j)enetrate  into  the  antrum,  and  from  such  roots,  if 
carious,  iniiannnation  can  pass  to  the  mucous  lining  of  the  sinus. 
Also,  when  such  diseased  molar  is  extracted,  the  floor  of  the  cav- 
ity may  be  opened,  and  through  such  opening,  as  Duplay  has 
pointed  out,  particles  of  food  may  pass  and,  lodging  in  the  antrum, 
cause  inflammation  and  eventually  pus  in  the  cavitv.  Also,  the 
continuity  of  the  nasal  mucous  membrane  with  the  lining  of  the 
antrum,  fonns  a  way  by  which  disease  in  the  nasal  fossae  travels 
to  the  sinus;  thus  chronic  catarrh  and  nasal  polypi  have  led  to 
suppurative  inflammation  in  the  antrum. 

Such  pus  being  long  retained  in  the  antrum  becomes  thick, 
caseous,  and  of  foul  odor,  or  it  may  be  thin  like  serum.  The 
contact  of  this  material  with  the  containing  wall  causes  disinte- 
gration and  necrosis,  and  the  final  result,  in  most  cases,  is  tlie 
perforation  of  the  wall ;  yet  in  some  instances  the  wall,  instead 
of  being  attenuated,  is  thickened. 

The  primary  symptoms  of  such  inflammation  is  a  dull,  con- 
tinuous or  pulsating  pain  in  the  region  of  the  cheek.  The  tears 
flow,  and  finally  there  is  a  fullness  and  swelling  of  the  corre- 
sponding cheek.  As  tiie  pus  accumulates,  the  antrum  is  enlarged 
through  the  yielding  of  the  front  or  inner  walls.  Or  the  palatine 
floor  of  the  cavity  may  be  forced  downwards,  or  the  floor  of  the 
orbit  uplifted.  From  such  eccentric  swelling,  therefore,  the 
cheek,  palatine  vault,  nasal  passage,  or  eye  may  be  encroached 
upon,  and  functional  disturbance  be  produced.  Frequently,  in- 
stead of  thus  enlarging  when  the  antrum  becomes  filled  with 
pus,  the  pressure  reopens  the  passage  into  the  middle  meatus, 
whereupon  the  material  escapes  into  the  nose,  and  presents  itseli 
in  front  or  in  the  throat.  If  such  escape  through  the  natural 
way  does  not  appear,  then  the  pus  may  perforate  the  attenuated 
wall  and  form  a  fistula.  Such  fistula  has  formed  through  the 
cheek  below  tlie  eye,  or  through  the  canine  fossa  into  the  mouth,  or 
through  the  floor  of  the  antrum.  The  fistula  has  passed  directlj'' 
into  the  oral  cavity.  It  is  especially  troublesome  and  conspicu- 
ous when  situated  in  the  cheek,  and  is  most  fortunately  situated 
when  it  passes  through  the  alveolar  process,  or  through  the 
canine  fossa,  emerging  between  tlie  lip  and  the  alveolar  process. 
In  many  cases  the  opening  is  so   situated  that  the  pus  cannot 


ABSCESS   OF   THE   MAXILLARY   SINUS.  395 

wholly  escape,  and  a  part  remaining  becomes  extremely  fetid; 
and  where  the  opening  is  through  the  inner  wall,  the  case  might 
be  mistaken  for  an  affection  of  the  nasal  fossa. 

Suppurative  inflammation  of  the  antrum  is  diflacult  to  diag- 
nose in  the  beginning,  for  the  reasons  that  the  symptoms  are 
similar  to  those  which  attend  disease  in  the  roots  of  the  teeth, 
an  abscess  in  the  gingival  tissue,  or  a  facial  neuralgia.  The 
purulent  collection  in  the  antrum  will  soon  reveal  itself  by  excen- 
tric  protrusion  of  one  or  more  of  the  containing  walls;  and  this 
wall,  when  pressed  on,  yields  with  the  crackling  sound  of  parch- 
ment. But  to  banish  all  doubt,  a  small  trocar  can  be  thrust 
through  the  wall,  and  the  pus  brought  to  view. 

Treatment. — It  may  happen  that  the  pus  may  escape  through 
a  perforation  so  situated  that  the  entire  content  can  escape,  and 
the  sinus  gradually  return  to  its  normal  condition,  and  the  out- 
let of  escape  finally  close.  This  occurs  when  the  outlet  is  at  the 
most  dependent  portion  of  the  cavity.  Nature,  unaided,  seldom 
opens  at  a  point  most  favorable  for  recovery,  viz.,  the  perfora- 
tion is  oftenest  somewhere  above  the  floor  of  the  antrum,  and 
consequently  surgical  aid  is  required. 

When  the  choice  of  site  for  the  opening  is  left  to  the  option 
of  the  surgeon,  he  may  choose  to  open  through  the  alveolar  pro- 
cess, or  above  this,  through  the  lower  part  of  the  anterior  wall  in 
the  canine  fossa.  Most  surgeons  prefer  to  open  through  the 
alveolar  process;  and  they  do  this  by  sacrificing  a  tooth,  if  this 
has  not  already  been  lost.  The  opening  may  be  bored  with  a 
drill  through  the  alveolar  depression  of  the  first  or  second  molar 
tooth;  the  second  molar  is  preferred.  Should  one  of  the  molars 
be  carious,  that  one  should  be  extracted.  The  writer  greatly 
prefers  to  open  through  the  canine  fossa,  since  when  the  work  is 
done  there  the  opening  can  afterwards  be  closed.  To  operate 
here  incise  upwards  close  to  the  canine  fossa  of  the  upper  jaw; 
then,  having  separated  and  elevated  the  detached  soft  parts,  an. 
opening  is  to  be  made  with  a  small  trephine  or  a  curved  chisel. 
Through  the  opening  thus  formed  the  cavity  is  to  be  thoroughly 
cleansed  with  water  slightly  acidulated  with  nitric  or  hydro- 
chloric acid.  The  opening  is  to  be  maintained  open  by  means  of 
a  drainage  tube,  through  which  the  cleansing  irrigation  can  be 
repeated  daily.  And,  as  fluid  for  this  purpose,  one  may  use  a 
solution  of  sulphate  of  zinc,  five  grains  to  the  ounce;  or  one  of 
chloride  of  zinc,  two  grains  to  the  ounce;  or  of  alum,  five 
grains  to  the  ounce.     Should  there  be  much  fetor  in  the  dis- 


396  MAXILLARY    SINUS,    OR    ANTRUM    <)U    JIKillMORE. 

charge,  an  antiseptic  fluid  should  be  used  for  the  irrigation,  and 
then  dihite  chlorinated  water,  or  a  solution  of  chloride  of  lime, 
or  of  permanganate  of  jiotash,  of  which  one  can  use  Condy's  solu- 
tion diluted,  as  follows: — ■ 

li.     Potassii  Permanganatis 3! 

Aquae 3x 

Miscc. 

Since  some  of  these  solutions  are  toxic  in  action  if  swallowed, 
care  must  be  taken  in  their  use  that  the  fluid  does  not  escape 
from  the  buccal  cavity  into  the  throat  and  be  swallowed.  Sucli 
irrigating  fluid  can  flow  through  the  orifice  in  the  inner  wall  of 
the  sinus,  and  thence  pass  into  the  pharynx;  to  prevent  this  lot 
the  patient's  head  be  inclined  forwards  during  the  irrigation;  and 
then,  if  the  fluid  enters  the  nose,  it  will  esca])e  through  the  ante- 
rior nares.  To  do  this  irrigation,  an  elastic  tubular  syringe  may 
be  employed.  This  work,  for  a  time,  should  be  done  by  the  sur- 
geon; later,  the  patient  can  do  it  himself,  with  the  occasional 
supervision  of  his  medical  attendant.  After  the  sinus  has  thus 
been  restored  to  a  healthy  state,  the  outlet  may  be  allowed  to 
close,  provided  there  exists  an  outlet  into  the  nose,  and  if  one  does 
not  exist,  one  could  be  made  from  the  middle  meatus  into  the 
sinus,  by  means  of  some  sharp,  perforating  instrument,  for  exam- 
ple, a  blunt  dissector  or  a  small  curved  chisel.  The  inner  wall 
is  fragile  and  can  readily  be  fractured.  Should  the  opening- 
made,  through  the  front  wall  for  irrigating  not  close  sponta- 
neously, it  can  be  done  by  trimming  the  borders  of  the  opening 
and  uniting  them  by  sutures.  In  case  the  sinus  proves  not  to  be 
restored  to  health,  as  shown  by  the  escape  of  fetid  excreta  from 
the  nose,  then  the  opening  in  the  canine  fossa  should  be  resorted 
to,  and  the  irrigation  continued  for  a  longer  period. 

FiMula  of  the  Antrum. — From  the  purulent  collection  in  the 
sinus  bursting  through  the  anterior,  superior  or  inferior  wall,  a 
fistulous  opening  may  form,  which  may  remain  an  indefinite 
time  unless  surgically  relieved.  According  to  its  situation,  this 
fistula  might  heal  spontaneously,  or  remain  open;  if  it  were  in 
the  roof  of  the  mouth,  or  were  above  the  alveolar  process  within 
the  buccal  cavity,  the  fistula  might  close  after  the  sinus  had 
ceased  to  excrete  diseased  matter;  but  if  the  opening  were  througli 
the  cheek,  or  the  floor  of  the  orbit,  then  the  fistula,  without  some 
surgical  aid,  would  be  permanent. 

The  diagnosis  of  this  fistula  can  readily  be  made  when  the 


CYSTS    IN    THE    ANTRUM.  397 

previous  history  of  the  disease  has  been  considered,  and  all 
obscurity  vanishes  if  a  probe  be  passed  through  the  opening  into ' 
the  cavity.  Such  diagnostic  exploration  being  once  made  by  an 
English  lady,  the  feather  she  used  passed  so  deep  into  her  face 
that  she  became  alarmed  and  feared  she  had  entered  her  brain. 
She  consulted  her  physician,  Nathaniel  Highmore,  who  relieved 
her  fears  by  his  explanation,  and,  publishing  the  case,  he  gained 
for  his  name  an  undying  place  in  Anatomy  as  the  discoverer  of 
this  sinus,  though  it  l*ad  previously  been  known  to  Galen. 

Treatment. — If  the  fistula  be  situated  so  as  to  constantly  draiji 
the  antrum,  the  treatment  need  only  consist  of  simply  irrigating 
the  sinus  with  an  antiseptic  fluid,  which  would  accelerate  the 
healing.  But  if  the  fistula  perforate  the  cheek  or  pass  out  beneath 
the  eye,  then  the  task  of  closing  and  permanently  healing  it 
becomes  more  difficult.  The  work  will  then  commence  by  mak- 
ing an  opening  through  the  canine  fossa  within  the  mouth; 
afterwards  enlarge  the  fistula,  and,  through  the  opening,  remove 
any  dead  structure  which  may  exist  in  the  bone,  and  then  trim 
the  walls  of  the  sinus  and  close  accurately,  with  sutures.  Cleans- 
ing irrigation  of  the  sinus  must  then  be  continued,  until  the 
walls  are  restored  to  integrity;  and  then  the  provisional  open- 
ing may  be  permanently  closed,  provided  the  normal  opening 
through  the  inner  wall  is  patent.  The  patency  can  be  determined 
by  filling  the  sinus  with  fluid,  when  the  latter  will  flow  into  the 
nose,  if  there  exist  an  outlet;  and  if  no  outlet  exists,  an  artificial 
one  can  be  established.  To  do  this,  pass  an  instrument  through 
the  opening  made  in  the  front  wall,  and  bore  through  the  inner 
one  near  its  middle  point,  and  retain  this  open  by  means  of  a 
drainage  tube,  passed  from  the  outer  to  the  inner  wall.  As  soon 
as  the  outlet  into  the  nasal  passages  is  permanently  established, 
then  the  intra-buccal  w^ound  of  the  soft  parts  on  the  canine  fossa 
can  be  closed  by  trimming  its  margins,  and  closing  by  sutures. 

Where  there  is  a  collection  of  retained  pus  or  ichor  in  the 
sinus,  instead  of  escaping  by  a  small  opening,  a  large  portion  of 
a  wall  may  become  necrosed,  and  be  detached  and  eliminated. 
Such  a  case  the  author  observed  in  a  child  eight  years  of  age ;  a 
portion  of  the  anterior  wall  was  thrown  off"  through  an  ulcerative 
breach  in  the  cheek.  The  detachment  of  the  bone  w^as  confided, 
in  this  case,  to  nature,  and  the  result  was  a  sunken,  permanent 
scar. 

Cysts  in  the  Antrum. — The  mucous  glands  of  the  lining  wall  of 
the  antrum  have  been  studied  by  Giraldes,  who  finds  that  tlieir 


39S  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGIIMORE. 

excretory  ducts  or  outlets  tend  to  closure  and  obliteration,  and 
thus  the  retained  content  forms  a  cyst  through  retention.  Such 
cysts  of  moderate  volume,  M'hich  had  not  been  suspected,  are  often 
found  in  the  antrum.  The  cyst  may  be  so  located  as  to  occlude 
the  normal  outlet  of  the  antrum,  and  thus  the  cavity  may  be 
filled  with  muco-serous  content;  or  the  fusion  and  growth  of 
several  of  these  cysts  can  form  a  large  one,  filling  the  antrum. 
Thus  Giraldes  explains  the  origin  of  what  is  sometimes  erro- 
neously named  droi)sy  of  the  antrum.  The  small  cysts,  seldom 
exceeding  the  size  of  a  pea,  cause  no  inconvenience;  a  large  one 
may  encroach  on,  and  force  outwards,  the  containing  walls. 
Such  swelling  can  be  discovered  by  everting  the  upper  lip  and 
pressing  on  the  front  wall,  wdien  a  crepitating,  parchment-like 
sound  will  be  felt,  as  the  attenuated  wall  yields  under  the  finger. 
The  encroachment  on  the  inferior  wall  may  have  worse  conse- 
quences; the  palate  may  be  depressed  and  the  alveolar  arch 
widened,  and  the  teeth  caused  to  fall  from  their  sockets;  or  from 
upward  crowding,  exophthalmos  may  be  produced.  The  lachry- 
mal canal  is,  fortunately,  rarely  interfered  with.  To  sum  up, 
then,  as  functional  troubles  from  such  cyst,  there  may  be  disturbed 
mastication,  respiration  and  vision; and  exceptionally  the  walls 
become  thicker,  and  then  they  will  not  yield  under  pressure. 

Treatment. — This  consists  in  opening  through  the  canine  fossa, 
and  emptying  the  content;  and  to  prevent  re-formation  of  the 
cyst,  an  iodized  solution  should  be  injected,  from  time  to  time, 
into  the  cavity,  tlirough  the  artificial  opening.  Should  the 
normal  opening  into  the  nasal  passage  be  occluded,  this  must  be 
restored  in  the  manner  already  described  when  treating  of  abscess 
in  the  antrum. 

Tumor  of  the  Maxillary  Sinus. — As  neoplastic  growths  appear- 
ing in  the  antrum  are  the  mucous  polypus,  the  enchondroma, 
sarcoma,  carcinoma  and  osteoma. 

The  mucous  polyj),  similar  to  that  occurring  in  the  nose,  has 
been  seen  in  the  antrum.  Cartilaginous  growths  as  well  as  the 
more  malignant  forms  of  tumor  have  originated  within  this 
cavity,  and  continued  to  grow  until  they  crowded  upon  and  dis- 
placed tlie  contaniing  w'alls;  and  such  displaced  wall  presses  on 
parts  contiguous,  and  disturbs  their  function.  This  anterior  pro- 
trusion will  disturb  the  contour  of  the  cheek,  and  change  facial 
expression;  if  directed  towards  the  roof  of  the  sinus,  the  orbital 
floor  may  be  uplifted,  the  eye  di.splaced,  and  double  vision  be 
produced.    Growth  and  pressure  downwards  will  encroach  on  the 


TUMOR    OF    THE    MAXILLARY   SINUS.  399 

bony  palate  and  alveolar  arch,  and  thence  result  destruction 
of  the  teeth.  Growth  inwards  towards  the  nasal  passage  will 
crowd  on  the  latter  and  impede  breathing.  The  tumor  does 
not  end  its  baleful  march  at  mere  functional  disturbance;  it 
presses  on  the  structures  which  it  meets  until  it  opens  a  way- 
through  them  by  ulcerative  action;  and  thus  the  tumor  presents 
itself  to  view,  in  many  cases.  The  pressure  on  branches  of  the 
trifacial  nerve,  during  this  devastating  march,  causes  severe  and 
agonizing  pain. 

The  treatment  must  be  directed  to  a  radical  and  complete 
extirpation  of  the  growth  as  soon  as  its  presence  has  been  indi- 
cated by  some  phase  of  the  functional  disturbance  which  has 
been  mentioned.  And  when  suspected  and  not  clearly  indicated, 
an  intra-oral  incision  may  be  made  through  the  canine  fossa. 
When  discovered,  the  tumor,  whether  polypoid,  enchondromatous 
or  cancerous,  may  be  removed  through  the  following  incision: 
Cut  and  separate  the  upper  lip  from  the  superior  maxilla,  and 
then  retract  the  separated  soft  parts  from  the  jaw  by  a  large 
retractor;  remove  or  uplift  the  front  wall  of  the  antrum,  so  that 
its  contents  can  be  inspected,  and  extract  the  neoplasm  which  is 
discovered.  Should  the  incision  mentioned  not  suffice  for  the 
complete  extraction,  then  it  may  be  enlarged  by  another  cut 
extending  vertically  from  the  inner  angle  of  the  eye  to  and 
through  the  upper  lip.  And  should  it  be  possible,  this  flap 
should  contain  a  portion  of  the  front  bony  wall  of  the  antrum, 
which  has  been  sawn  through  with  an  exsection  saw.  The 
triangular  flap,  thus  formed,  can  then  be  drawn  outwards  and 
upwards,  and  thus  a  much  larger  field  will  be  opened  for 
exsecting  the  contents  of  the  antrum.  In  case  the  tumor  be 
found  to  be  malignant,  then  the  entire  upper  jaw  must  be 
removed.  But  if  the  growth  has  previously  been  diagnosticated 
to  be  of  benign  nature,  then  the  front  wall  having  been  uplifted 
along  with  the  soft  parts,  after  the  growth  has  been  removed,^  the 
osteo-cutaneous  flap  can  be  replaced,  and  thus  the  form  of  the 
cheek  preserved. 

Osteoma  may  originate  within  the  maxillary  sinus  and  attain 
dimensions  which  may  encroach  on  the  parts  contiguous,  and 
cause  functional  disturbance.  An  instance  of  the  kind  came 
under  the  writer's  observation.  In  the  patient,  a  woman  of  twenty 
years  of  age,  a  deformity  of  the  right  cheek  and  roof  of  the 
mouth  gradually  appeared;  also  the  right  eye  was  shifting  its 
position  upwards,  and  double  vision  was  present.     It  was  appar- 


4UU  MAXILLAKV    iSlNUS,    OR    ANTRUM    OF    IIIGIIMORE. 

ent  that  tlie  upi)er  jaw  was  enlarging;  and  a  growth  within  the 
antrum  was  inspected,  and  an  operation  for  its  removal  counseled. 
To  do  this  it  was  decided  to  do  the  work  without  external  incision, 
viz.,  by  separating  the  iipper  lip  and  cheek  from  the  maxilla. 
The  loosened  i)arts  being  retracted,  a  portion  of  the  front  wall 
corres[)onding  to  the  canine  fossa  was  removed  with  the  mallet 
and  chisel.  It  was  found  that  the  bone  removed  was  very  hard, 
and  that  no  vestige  of  an  antrum  existed.  The  excision  of  the 
bone  was  continued  b}^  means  of  chisel  and  mallet,  until  a  large 
portion  of  the  upper  jaw  was  excised,  and  a  cavity  left  of  larger 
dimensions  than  the  normal  antrum.  The  osseous  exsection 
revealed  the  fact  that  the  antrum  was  entirely  obliterated,  and 
the  enlarged  maxilla  consisted  of  bone  of  unusually  dense  nature; 
the  bone  was  of  ivory-like  hardness,  and  its  removal  was  a  task 
of  the  most  tedious  and  tiresome  manual  labor.  The  walls  of 
the  jaw  were  left  except  a  })art  of  the  anterior  one.  Not  much 
bleeding  occurred.  One  tooth  was  loosened  in  the  work  and  was 
removed.  Some  anaesthesia  which  existed  prior  to  the  operation 
was  not  relieved  by  the  exsection.  The  cavity  made  was  filled 
with  alcoholized  lint;  and  this  treatment  was  continued  for 
many  months,  during  w'.iich  time  fragments  of  bone  detached 
themselves  from  the  surface  which  had  been  chiseled  off.  The 
granulative  tissue  which  appeared  on  the  inner  surface,  later 
became  a  tissue  which  resembled  the  normal  lining  of  the 
alveolar  proce.s.ses.  The  extruded  orbital,  malar  and  palatal 
walls  gradually  resumed  normal  position,  until  from  the  eye, 
cheek,  and  roof  of  the  mouth  there  vanished  all  aberration  of 
form;  the  right  side  of  the  face  was  not  distinguishable  from  the 
leftside;  a  condition  different  from  what  would  have  been  the 
case  had  the  work  been  done  through  an  external  cut;  and 
certainly  far  different  from  tlie  aspect  which  the  patient  would 
have  presented  had  the  entire  upper  jaw  been  removed  as  had 
been  counseled  to  the  patient  by  less  conservative  surgery.  The 
lapse  of  five  years  now  gives  immunity  from  recurrence  in  this 
case;  yet  to  observe  the  condition  of  the  interior  of  the  cavity, 
the  labio-alveolar  incision  was  allowed  to  remain  open. 

In  this  osteomatous  growth  it  was  not  determined  whether 
the  tumor  originated  in  the  antrum,  and  grew  eccentrically,  or 
whether  it  was  a  general  hypertrophy  of  the  maxilla  superior, 
in  which  the  bone  grew  both  centrally  and  eccentrically. 

Perforation  of  the  Nasal  Septum. — The  cartilaginous  septum  of 
the  nose  is  often  the  site  of  ulcerative  action,  which  sometimes 


PERFORATION    OF    THE    NASAL    SEPTUM.  401 

perforates  the  part  and  forms  an  opening  of  greater  or  less  extent 
between  the  nares.  This  ulceration  is  oftenest  seen  in  the  scrof- 
ulous and  syphilitic  subject,  yet  it  also  occurs  in  subjects  of  other- 
wise normal  health.  The  point  where  the  ulcer  oftenest  com- 
mences is  at  the  junction  of  the  cartilage  "u-ith  the  loAver  part  of 
the  partition.  Where  this  muco-dermal  border  joins  the  carti- 
lage above,  the  partition  is  thinner  than  elsewhere;  and,  from  the 
mobility  of  the  parts  here,  this  thin  part  might  with  some  ana- 
tomical license  be  named  a  joint  of  the  nose.  The  mobile  nature 
of  this  structure  predisposes  it  to  lesion,  and  explains  the  frequent 
commencement  of  ulcerative  action  at  this  point;  and  the  breach 
commencing  here,  its  enlargement  is  promoted  by  the  same 
cause,  and  by  the  habit  of  the  patient  of  industriously  promoting 
the  extension  of  the  ulceration  bv  often  touching;  and  examinino- 
it,  and  especially  by  the  mischievous  habit  of  often  detaching 
the  encrusted  scab  which  adheres  to  it.  Under  these  influences 
an  insignificant  initial  lesion  is  enlarged  and  deepened  until  it 
perforates  the  attenuated  w^all.  This  ulcer  extends  upwards  into 
the  adjacent  cartilaginous  septum;  the  cutaneous  margin  under- 
neath does  not  ulcerate,  or  only  in  exceptional  cases;  and  hence 
the  patient  is  spared  the  exposure  of  his  ill,  as  would  be  the  case 
if  the  lower  margin  of  the  septum  w^ere  opened  by  ulceration. 
The  extension  uj) wards,  and  immunit}^  of  the  sub-septum,  depend 
on  the  lower  vitality  of  the  cartilage. 

From  an  extensive  observation  of  such  ulceration,  the  writer 
has  remarked  that  this  otherwise  trivial  ailment  is  often  the  source 
of  much  annoyance  to  its  subject:  his  apprehensive  fancy  descries 
in  the  future  some  mutilation  of  figure.  This  mutilation  is  rarely 
realized,  as  the  ulceration  seldom  reaches  great  limits;  it  is  infre- 
quent that  an  opening  greater  than  that  which  would  admit  the 
end  of  a  finger,  arises.  Yet  this  small  breach  cannot  be  closed, 
and  to  stay  its  enlargement  is  no  easy  task.  The  treatment  is,  in 
the  main,  of  topical  character,  though  any  concurrent  cachexy 
must  be  met  with  appropriate  remedies.  As  a  local  means,  is 
the  compound  tincture  of  benzoin,  applied  daily  with  a  camel 
hair  brush.     Or  an  ointment  of  ammoniated  mercury,  viz: — 

^.  Hydrargyri  Ammoniati partes  10 

Adipis partes  90 

Misce. 

Apply  once  daily  after  the  removal  of  the  crust.  Also,  an  oint- 
ment of  quinine,  in  tlie  proportion  of  ten  grains  to  the  ounce  of 


402  MAXILLARY    SINUS,    OR    ANTRUM    OF    IIIOHMORE. 

vaseline.  An  ointment  of  calomel,  in  the  proportion  of  six  grains 
to  the  ounce,  acts  well.  The  site  of  the  ulcer,  so  located  as  to 
receive  and  retain  the  excreta  in  their  esca})e  from  the  nasal  fossa, 
is  so  unfavorable  to  healing  that  often,  despite  attentive  treat- 
ment, the  ulcer  persists.  As  ultimate  resort,  the  ferrum  candens 
or  the  thermal  cautery  may  be  used,  and  the  ulcerated  surface 
slightly  cauterized. 

In  cases  which  have  come  under  treatment  after  the  septum 
is  perforated,  the  best  that  can  be  hoped  is  a  cure  with  an  open- 
ing between  the  iiares;  though  such  condition  is  unsatisfactory 
to  the  patient,  yet  he  can  be  confidently  assured  that  no  func- 
tional impairment  can  result  from  it  as  regards  breathing, 
smelling  or  S})eaking;  these  functions  will  be  as  perfect  as  before 
the  perforation;  and  as  the  defect  is  comi)letely  hidden  from 
siirht,  it  is  relieved  from  most  of  the  odium  which  attaches  to  a 
corporeal  deformity. 

Nasal  Deformity  and  Means  employed  for  its  Relief — There  may 
be  a  deformity  of  the  nose  from  excessive  volume;  likewise,  from 
abnormal  shape  of  natural  volume;  and,  lastly,  deformity  may 
arise  from  defect  in  which  a  portion  or  the  entirety  of  the  exter- 
nal nose  is  absent. 

Deformity  from  excess  of  volume  is  rarely  congenital;  it  is 
oftener  acquired.  There  is  rarely  excessive  volume  of  the  entire 
nose;  the  hypertrophy  usually  affects  the  lobule,  or  lower  half  of 
the  nose.  Reference,  however,  has  already  been  made  to  this,  as 
well  as  to  the  means  of  relief  by  the  excision  of  cuneiform  sections 
and  closure  by  suture.  By  such  method,  excess  of  structure  of 
anv  part  of  the  external  nose  may  be  successfully  corrected.  In 
thi.G  retrenching  excision,  care  must  be  used  not  to  remove  too 
much;  for  a  nose  rendered  too  small  offends  the  e^'e  of  both 
observer  and  observed,  quite  as  much  as  one  of  excessive  pro- 
portions. Also,  if  the  proportions  be  asymmetrical,  the  effect 
will  be  unsatisfactory.  To  avoid,  therefore,  error  on  the  side  of 
excessive  removal,  the  cuneiform  excision  should  only  be  done 
on  a  minimal  scale;  and,  if  need  be,  more  structure  could  after- 
wards be  removed;  but  if  the  excision  have  been  too  freely  done, 
no  subsequent  work  can  efface  or  correct  it. 

It  sometimes  occurs  that  a  nose  which  isnormal  in  the  amount 
of  its  component  structure,  is  still  so  irregular  in  one  or  more  of 
its  outlines  that  it  is  disagreeably  conspicuous,  and  is  a  source  of 
no  small  vexation  to  its  unlucky  owner.  As  examples  of  such 
ill  form,  the  following  may  be  enumerated:  dorsal  depression  or 


NASAL    DEFORMITY.  403 

dorsal  elevation  of  the  nose;  deviation  of  the  lobule  to  one  side; 
deviation  of  the  entire  nose  to  one  side;  unusual  prominence  of 
the  sub-septum,  or  recession  of  the  same.  If  any  nose  be  care- 
fully examined,  a  trace  of  one  or  more  of  the  defects  mentioned 
may  be  found;  and  often  this  trace  of  ill  shape,  which,  without  an 
effort  on  the  part  of  the  searcher  to  detect,  would  remain  unob- 
served, becomes  so  magnified  in  the  eye  of  the  subject  that  a 
surgeon  is  consulted.  The  duty  of  the  surgeon  in  such  case  is  to 
endeavor  to  convince  his  patient  that  his  ill  is  unimportant,  and 
that  the  offending  feature  is  seen  by  no  one  except  himself.  The 
task  of  the  consultant  is  not  an  easy  one;  for  nothing  is  more 
difficult  than  to  expel  from  the  human  head  a  tormenting  fancy 
which  has  once  been  admitted  there.  Such  fancy  often  eludes  the 
best  directed  weapons  of  reason. 

In  the  cases  of  this  class,  the  slighter  the  deformity,  the  greater 
is  th©  difficulty  of  relieving  it  by  operative  means,  for  the  opera- 
tion usually  only  substitutes  one  ill  feature  for  a  new  one;  hence, 
in  such  cases,  the  discreet  surgeon  will  counsel  non-interference, 
a?nd  pursue  this  policy  even  though  the  patient  does  not.  But 
where  the  deformity  is  such  that  it  continually  attracts  observa- 
tion, an  attempt  to  correct  it  is  justifiable;  yet  here  as  in  all  sur- 
gical work  which  is  done  solely  from  cosmetic  motive  and  pur- 
pose, the  patient  must  be  forewarned  that  the  best  planned  schemes 
here  often  go  awry;  and  also,  that  success  often  fails  to  bring 
content,  even  as  those  who,  dissatisfied  with  their  lots,  are  allowed 
to  change  them  in  accord  with  their  praying;  for  many 
are  still  unhappy;  so  that,  as  the  Horatian  Muse  tells  us,  the 
grantor,  Jupiter,  inflates  his  cheeks  with  rage,  and  declares  that 
in  future  he  will  not  give  so  facile  an  ear  to  human  prayers. 
The  surgeon,  like  Jupiter,  who  is  persuaded  to  engage  in  cosmetic 
work  contrary  to  his  judgment,  sometimes  regrets  that  he  has 
yielded  to  the  suppliant. 

A  deforming  condition,  in  which  intervention  may  be  per- 
mitted, is  that  in  which,  from  accident  or  other  cause,  the  nose  has 
been  deflected  to  one  side,  and  the  nasal  passages  are  lessened  by 
being  encroached  upon.  Restoration  to  form  here  has  been 
attempted  by  the  writer  by  endeavoring  to  fracture  the  deviated 
walls  of  the  nose.  The  fracture  of  the  nasal  bones,  though  so 
easily  occurring  through  accident,  is  no  easy  task  for  the  surgeon. 
Should  it  be  attempted,  the  work  may  be  done  by  blows  of  a 
mallet  upon  a  plate  of  metal  laid  on  the  side  of  the  nose,  a  piece 
of  lint  meantime  being  interposed  between  the  plate  and  the  nose. 


404  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGIIMORE. 

To  accomplish  anything,  violent  blows  must  be  struck:  force 
enough,  in  fact,  to  endanger  the  encephalic  structures  through 
concussion.  And  though  fracture  may  be  thus  caused,  it  will  be 
found  of  little  aid,  since  the  broken  bones  are  so  little  movable 
that  form  cannot  be  satisfactorily  repaired.  An  effort  to  fracture 
excentrically,  that  is,  from  the  inside  of  the  nose,  might  prove 
more  successful;  to  do  this,  first  plug  the  nostrils  posteriori}',  and 
then  introduce  a  lever  into  each  nostril,  and,  resting  on  a  fulcrum, 
pry  against  each  side  until  the  bony  wall  is  loosened  and  mova- 
ble. The  work  of  reposition  is  completed  by  modeling  the 
loosened  sides,  and  supporting  them  from  beneath  by  tubular 
supports.  Even  this  method,  as  the  author  has  verified,  is 
attended  by  difficulties,  and  the  result  obtained  is  far  from  satis- 
factory. It  is  probable  that  the  work  might  be  done  more  satis- 
factorily b}^  a  preliminary  division  of  the  nasal  bones.  To  do  this, 
after  posterior  occlusion  of  the  nasal  passages,  from  the  inner  face, 
saw  through  each  nasal  bone  near  its  lateral  border.  The  deflected 
nose  being  thus  loosened  at  its  sides,  the  deviated  part  might  be 
restored  to  approximately  normal  position,  without  any  external 
wound. 

Tubular  supports  in  the  nose,  aided  by  lateral  compresses  on 
the  outside,  may  be  used  to  retain  in  site  the  restored  part.  And 
should  the  osseous  division  mentioned  be  insufficient,  additional 
sawing  might  be  done  from  the  inside,  also  division  of  the  tether- 
ing bands  could  be  done  subcutaneously  by  means  of  a  tenotome. 
The  princi})les  here  given  may  serve  as  guiding  rules  for  improve- 
ment of  form,  in  cases  of  displacement  or  deviation  of  one  of  the 
nasal  bones.  And  in  every  case,  the  operator  should  bear  in 
mind  that  the  calibre  of  the  nasal  passages  must  not  be  so 
encroached  upon  as  to  interfere  with  respiration,  and  to  avoid 
this,  |)atency  must  be  maintained  by  large  tubular  supports  dur- 
ing treatment;  the  objective  side  must  not  overshadow,  or  cause 
to  be  forgotten,  the  subjective  one;  for  the  ])atient  will,  erelong, 
prize  the  faculty  of  free  nasal  breathing  more  than  the  form  of 
the  nose. 

xVnotlier  minor  defect  of  form  whicii  may  solicit  correction, 
is  unusual  prominence  of  the  sub-septum  ;  for  when  this  depends 
beyond  the  alse,  the  aspect  is  unsightl3^  The  remedy  for  this 
consists  in  excision  of  a  })ortion  of  the  contiguous  cartilaginous 
septum  ;  and  then,  having  lifted  the  prominent  part  upwards, 
fasten  it  by  suture  in  the  space  formed.  The  excision  of  the  car- 
tilage can  be  done  without  severing  the  sub-septum,  either  from 


NASAL    DEFORMITY.  405 

the  lip  or  the  nasal  lobule.  Scrupulous  care  must  be  taken  not 
to  remove  too  much  of  the  septum,  for  by  so  doing,  the  lower  border 
of  the  sub-septum  would  be  rendered  concave,  and  an  unsightly 
feature  created;  the  excision,  then,  should  be  done  piecemeal, 
until  it  is  found  that  a  sufficient  amount  has  been  removed  to 
repair  the  defect. 

Again,  the  septum  may,  as  a  congenital  or  acquired  defect, 
not  reach  to  the  outlet,  the  alse  and  the  lobule  reaching  beyond 
it.  This  defect,  when  a  congenital  one,  would  rarely  demand  the 
surgeon's  aid;  yet  when  the  sub-septum  has  been  destroyed  by 
disease,  a  reparative  operation  should  be  done.  For  this  purpose 
material  from  the  upper  lip  can  be  used;  and  this  may  be  taken 
from  the  philtrum  or  middle  of  the  lip;  or  a  flap  with  pedicle 
towards  the  septum,  may  be  cut  obliquely  from  the  upper  iip,  as 
done  by  Despres.  If  the  upper  lip  were  unusually  high,  it  were 
better  to  utilize  material  from  the  median  part  of  the  lip.  For 
this  purpose,  make  an  incision  on  each  side  of  the  median  line 
through  the  lip,  so  as  to  form  a  flap  with  upward  pedicle,  and 
somewhat  broader  than  the  normal  septum.  Beneath  the 
lobule  make  a  raw  surface  to  which  the  replacing  flap  can  be 
attached;  also,  trim  off  the  edge  of  the  remaining  septum.  The 
flap  being  twisted  so  that  the  epidermal  face  will  look  out- 
wards it  is  fixed  by  sutures  to  its  destined  site.  Thus  done,  if 
the  twisted  pedicle  be  too  large,  after  a  month  it  can  be  given 
a  better  form  by  slight  incision;  or  to  avoid  this,  the  flap  not 
twisted  may  be  lifted  directly  upwards;  but  to  do  this,  the  outer 
surface  must  be  pared  off;  in  order  to  get  a  face  which  can  unite 
with  the  trimmed  edge  of  the  remaining  septum.  Besides,  the 
hair  roots,  if  not  removed,  would  occupy  a  very  inconvenient 
position  in  the  male's  lip.  Should  the  lip  be  thick,  the  deeper 
2)ortion  might  be  used  for  repairing  material.  To  do  this,  first 
make  a  median  vertical  cut  through  one-third  of  the  thickness  of 
the  lip;  from  the  bottom  of  this  cut  incise  laterally,  so  that  space 
is  gotten  through  which  a  flap  can  be  formed  from  the  deeper 
portion  of  the  lip.  This  flap  is  next  to  be  lifted  directly  upwards 
and  fixed  by  suture.  The  mucous  membrane  which  is  thus  ex- 
posed in  the  new-formed  sub-septum,  at  first  conspicuous,  will 
finally  acquire  the  appearance  of  ordinary  derm.  As  the  new 
material  lessens  by  contraction,  due  allowance  for  tliis  must  be 
made  in  the  work.  By  this  latter  mode  of  repair,  there  will  be 
less  sacrifice  of  the  labial  structure.  As  before  remarked,  Despres 
constructed  the  best  sub-septum  by  means  of  an  oblique  flap,  the 


40G  MAXILLARY    SINUS,    Oil    ANTRUM    oK    HIGIIMORK. 

loose  end  of  wliicli  lies  towards  the  left  tingle  of  the  mouth.  This 
must  be  twisted  so  that  the  dermal  side  will  look  outwards. 
And,  in  all  these  metliods,  the  wounds  created  must  be  closed  by 
catgut  suture. 

Rhinoplasty. — By  lihinoplasty  is  meant  an  operation  in  which 
there  is  repaired  or  restored  a  j)ortion  or  the  entirety  of  the 
nose;  and  such  operation  may  be  required  in  cases  in  which  the 
following  conditions  are  present: — 

1.  Partial  or  complete  loss  of  the  nose  through  some  violence, 
as  a  gunshot  wound  or  other  injury.  Along  with  the  nasal 
injury,  there  may  be  loss  or  lesion  of  parts  adjacent  or  subjacent, 
and  this  accessory  injury  may  be  so  great  as  to  render  any  rhino- 
plastic  restoration  difficult,  or  jjcrhaps  impossible. 

2.  Constitutional  disease,  as  syphilis,  may  destroy  the  nose, 
and  especially  some  malignant  growth,  as  carcinoma  or  epitheli- 
oma, frequently  destroys  a  large  jiortion  of  the  nose. 

3.  A  burn  yet  unhealed,  or  the  cicatrix  caused  h\  a  burn,  or 
by  the  destructive  action  of  an  acid  or  alkali,  may  demand  repair 
by  a  plastic  i)rocedure. 

4.  The  devastation  of  parts  by  the  surgeon's  knife  in  the 
removal  of  malignant  growths  involving  the  nose,  often  demands 
some  reparative  operation,  and  this  may  be  done  contemporane- 
ously with  the  operation,  or  at  a  later  ])eriod. 

Before  describing  the  procedure  for  repair  required  in  the  cases 
enumerated,  some  general  consideration  of  the  subject  of  rhino- 
plasty is  proper. 

The  Sanscrit  race,  which  early  inhabited  the  valley  of  the 
Ganges,  along  with  the  primal  germs  of  language,  gave  to  the 
nations  of  the  West  some  of  the  principles  of  medicine;  in  the 
Ayur-Veda,  a  book  on  medicine,  written  by  Susruta,  there  is 
mention  made  of  nose  building.  In  the  fifteenth  century  the 
Latin  race  surpassing  the  rest  of  the  world  in  enterprise,  doubled 
the  Ca[)e  of  Good  Hope;  and  it  is  probable  that,  as  the  art  of 
nose-repairing  appeared  at  the  same  era  in  Italy,  this  knowledge 
was  transplanted  there  from  the  Orient.  In  the  fifteenth  cen- 
turv  Branca,  a  Sicilian  surgeon,  formed  the  nose  from  the  skin 
of  the  face.  Branca's  son  went  further:  he  formed  the  nose 
from  structure  taken  from  the  arm.  In  the  sixteenth  century, 
Peter  and  Paul,  sons  of  a  family  named  Bojani,  residing  in 
Calabria,  also  constructed  the  nose  from  the  .'^kin  taken  from  the 
arm.  And  near  this  period  Tagliacozza,  j)rof(ssor  of  Anatomy  at 
Bologna,  in  Italy,  wrote  on  this  subject,  and  nt^nined  so  much 


RHINOPLASTY.  407 

repute  in  re-formation  of  the  lost  nose  that  he  was  honored  witli 
the  title  of  Xasifex,  or  nose-maker;  and  in  Latin  and  Eugiisli 
verse  iiis  handiwork  was  celebrated.  In  his  "Hudibras,"  Butler 
mentions  the  Talicotian  art  in  blunt  metre.  Talicotius,  as  his 
name  is  latinized,  is  thouo-ht  to  have  reallv  invented  nothinp-, 
and  the  charge  against  him  remains  unanswered,  that  he  inten- 
tionally and  disingenuously  aj)propriated  to  himself  the  work  of 
others.  The  Talicotian  operation  consisted  in  constructing  the 
nose  from  the  skin  of  the  arm,  as  had  already  been  done  by  the 
junior  Branca:  it  is  known  as  the  Italian  method.  It  consists  of, 
and  might  properly  be  named,  nasal  repair  by  transplantation. 
And  the  transplanted  material,  in  some  of  the  earlier  essays, 
seems  to  have  been  taken  from  the  body  of  another  person:  and 
as  the  theology  of  that  time  essayed  to  dictate  to  science,  and  had 
interpolated  much  material  in  the  structure  of  science,  it  is  no 
wonder  that  they,  whose  minds  had  the  crude  mold  of  that  time, 
feared  that  the  nose  constructed  of  another  man's  flesh  would 
die  when  the  original  owner  died.  We  are  not,  however,  told 
whether  there  was  fear  of  the  converse,  to  wit,  that  the  nose 
might  outlive  him  on  whom  it  was  engrafted. 

In  the  annals  of  surger}'  one  finds  examples  of  immediate 
transplantation  of  material  from  one  human  body  to  that  of 
another,  for  the  repair  of  the  defective  nose.  Unfortunately, 
these  accounts  have  often  been  derived  from  sources  in  which 
the  m^^thical  and  the  authentic  are  too  closely  commingled  for 
credence;  since  writers  then  did  not  always  confine  themselves  to 
historical  accuracy.  An  instance  of  this  kind  is  the  following: 
Dutrochet  reports  the  statement  of  his  brother,  who  had  been  in 
the  East  Indies,  that  a  criminal  who  had  been  punished  by  cut- 
ting off  his  nose,  had  his  loss  repaired  with  material  taken  from 
the  buttock  of  a  slave.  The  thick  integument  had  been  jDre- 
pared  for  transplantation  by  having  been  whipped  severely.  In 
this  way,  the  skin  became  surcharged  with  blood,  and  the  irrita- 
tion thus  caused  seemed  to  add  to  the  vitality  of  the  transplanted 
part.  The  site  to  receive  the  excised  skin  was  trimmed,  so  as  to 
render  it  raw,  and  fixation  was  effected  by  means  of  sutures.  It 
was  so  cut  as  to  furnish  material  also  for  a  septum.  It  is  stated 
that  a  good  result  was  obtained. 

Another  example  decidedly  apocryplial  is  that  told  of  an 
Italian  brigand,  whose  nose,  in  a  nocturnal  affray,  had  been  cut 
oflf.  Whilst  a  surgeon  was  deliberating  what  he  would  do,  the 
brigand's  confederates  attacked  a  passer-by  and  cut  off  his  nose, 


408  MAXILLARY    SINUS,    OK    ANTRUM    (>F    IIICIIMOKK. 

and  })iaced  the  same  on  the  face  of  their  companion.  This  na.si- 
ficial  exploit,  if  credible,  would  exceed  the  most  famous  deeds  of 
Talicotius  himself.  A  case  cognate  to  this  was  that  of  a  wealthy 
Frenchman  whose  nose  having  been  destroyed  by  lupus,  the 
proposal  was  made  to  his  servant  to  give  his  nose  to  his  master; 
though  a  promised  reward  of  many  ducats  accompanied  the 
request,  yet  the  attempt  was  not  made,  as  the  servant  valued  his 
nose  more  than  a  pocketful  of  ducats. 

An  authentic  case  of  direct  transplantation  from  one  part  of 
the  body  to  another,  is  tliat  reported  by  Biinger,  of  Marburg. 
The  movable  portion  of  the  nose  had  been  lost  in  a  woman,  aged 
thirty-three,  and  fruitless  endeavors  had  been  made  to  repair  the 
loss  from  adjacent  material  of  the  face.  Biinger  decided  to  make 
the  experiment  of  transplantation  of  repairing  material  from  a 
remote  part  of  the  body.  To  do  this,  assisted  by  his  colleague, 
Ullmann,  he  whipped  the  anterior  surface  of  the  tliigli  of  his 
patient,  and  excised  from  this  an  oval  flap  four  inches  long  and 
three  inches  wide,  and  applied  this  on  the  remaining  jjortion  of 
the  nose,  which  had  been  trimmed  for  the  purpose;  and  the  flnp 
was  fixed  by  sutures.  The  upper  portion  of  this  engrafted  flap 
lived ;  the  part  which  lived  seemed  to  do  so,  not  from  the  attached 
edges,  but  from  the  subjacent  surface,  which  was  raw  and  rested 
on  a  similar  surface.  There  lived  a  sufficiency  of  the  flap  to 
restore  the  greater  part  of  the  nose;  the  parts  lacking  wore  sup- 
plied by  the  adjacent  cheek  and  lip. 

Aside  from  these  adventurous  essays,  in  which  direct  trans- 
plantation of  tissue  from  a  distant  part  may  be  done,  the  rhino- 
plastic  procedure  as  commonly  practiced  consists  of  two  metliods, 
one  named  the  Indian,  in  wliicli  the  repairing  material  is  taken 
from  the  forehead  or  face;  the  other  named  the  Italian,  in  wdiicli 
the  material  of  replacement  is  derived  from  the  upper  arm  fore- 
arm, or  hand. 

The  Indian  method  consists  in  the  appropriation  of  the  dermal 
surface  of  parts  contiguous  for  the  repair  of  partial  or  entire  loss 
of  the  nose;  and  the  replacing  material  may  be  twisted  semi- 
circularly,  or  carried  to  its  destined  site  by  lateral  sliding.  This 
plan  of  replacement  is  sometimes  named  the  French  method, 
and,  again,  it  is  named  the  Celsian  method;  the  latter  name  is 
much  more  appropriate,  since  it  is  described  by  Celsus.  In  the 
lines  in  which  Celsus  has  described  this  w^ork, — lines  in  which 
intense  brevity  merges  into  obscurity, — the  student  has  the  first 
written  description,  spared  by  time,  of  surgical   work   done  to 


BHINOPLASTY.  409 

remove  or  conceal  defects  (curta)  in  tbe  face.  It  is  inferable  that 
the  Roman  race,  which  fearlessly  conquered  and  held  the  world 
in  its  martial  grasp,  had  the  weakness  of  quailing  before  facial 
defect,  and  that,  besides  for  glory,  the  Roman  would  suffer  pain 
for  cosmetic  purposes.  Celsus  has  a  chapter  entitled  "Defects  in 
the  ears,  lips,  and  nose;  in  what  manner  these  may  be  closed  and 
cured;"  the  chapter  opening  with  these  words:  "Defects  occur  in 
these  three  parts,  and  if  they  be  small  in  some  part,  they  can  be 
cured;  but  if  they  are  larger,  they  either  do  not  admit  of  remedy, 
or  the  result  is  such  that  the  part  is  rendered  less  comely  than 
it  was  before."  Since  these  lines  were  written,  the  truth  which 
they  contain  has  often  been  verified  by  ill-devised  and  ill-done 
work  within  the  sphere  of  plastic  surgery. 

The  manner  of  repairing  a  defect  in  the  ear,'  nose  or  lip  is 
stated  by  Celsus  in  the  following  words:  "Reduce  to  a  quadrate 
figure  that  which  is  defective  (curt);  from  the  interior  angles  of 
this  figure  incise  transverse  lines  which  may  separate  the  nearer 
structure  from  that  which  is  beyond;  then  unite  the  parts  together 
which  we  have  so  loosened.  But  if  the  parts  are  not  sufficiently 
united,  besides  the  incisions  which  we  have  made,  we  must  add 
two  other  incisions  of  crescentic  shape,  which  are  directed  towards 
the  wound  (already  made),  and  in  which  the  summit  only  of  the 
skin  is  separated;  thus  proceeding,  it  follows  that  what  is  drawn 
upon  easily  3'ields;  and  this  must  not  be  done  with  violence; 
the  traction  must  so  be  made  that  the  parts  easily  follow, 
and  when  they  are  abandoned  to  themselves,  they  recede  but 
little.  Likewise,  if  the  skin  at  one  part  is  not  entirely  closed,  it 
renders  the  part  ill-shapen.  In  the  manner  described,  then,  one 
portion  of  such  defect  is  to  be  incised,  while  the  other  portion 
must  be  left  intact.  We  shall  not  make  traction  on  the  following 
parts,  viz.,  the  lower  part  of  the  ears,  the  middle  of  the  nose,  the 
lower  part  of  the  nostrils,  nor  the  angles  of  the  mouth.  But  we 
will  seek,  for  replacing  materials,  on  each  side  of  the  defect,  in 
the  summit  of  the  ears,  in  the  middle  of  the  nasal  passages,  or  in 
the  middle  of  the  lips.  Defects  are  wont  to  be  in  two  places :  but 
here  the  method  of  cure  is  the  same  as  that  mentioned.  .  .  . 
Then  the  lips  of  the  wound  must  be  united  by  sutures,  the  skin 
being  pressed  together  from  each  side.  ...  In  the  inner 
incisions  as  well  as  in  the  crescentic  ones,  lint  must  be  inserted, 
in  order  that  the  growing  flesh  may  fill  the  wound." 

The  latter  portion  of  this  extract  from  Celsus  is  obscure.  To 
describe  mechanical  work  in  one's  vernacular  tongue  is  a  difficult 
27 


410 


MAXILLARY    SINUS,    OK    ANTRUM    OF    JIKillMoKE. 


task,  and  unless  illustrated  by  diagrams,  tlio  best  description  is 
vague,  and  scarcely  comprehensible;  and  the  obscurity  of  mean- 
ing is  still  greater  when  the  description  is  in  a  foreign  tongue,  or 
a  dead  language.  Yet  the  meaning  of  the  first  portion  of  the 
Celsian  citation  is  clear:  he  advises  to  convert  the  defect  into  a 
four-sided  figure,  and  then  to  elongate  the  incisions,  and  if  the 
sides  cannot  then  be  approximated,  to  make  subsidiary  incisions 
at  the  side  of  the  quadrangular  space,  so  as  to  facilitate  lateral 
sliding.  In  fact,  the  Celsian  method  is  the  equivalent  of  the 
Indian,  with  the  addition  of  accessory  cuts.  A  diagram  of  this 
work  is  shown  in  Figure  5.     The  crescentic  cuts,  instead  of  hav- 


a 

a. 

I 

A 

I 

B 

d 

Figure  5.     Showing   the  plastic  method    of   Celsus  (from  Otto  Weber); 
a^  a  b^  b  shows  the  defect  to  be  closed. 

ing  the  points  towards,  may  have  them  directed  from  the  figure. 
And  the  writer  would  suggest  that  instead  of  prolonging  the 
horizontal  lines,  as  shown,  it  would  be  better  to  do  this  after  the 
sides  were  approximated,  as  much  as  possible,  and  then  prolong 
them  above  and  below. 

As  indications  or  reasons  for  nasal  restoration  or  repair,  the 
following  may  be  offered:  A  face  without  the  external  nose  is 
eminently  repulsive  to  the  layman,  and  is  even  repugnant  to  the 
medical  man,  though  educational  molding  has  so  altered  his  taste 
that  he  often  finds  interest  in  contemplating  examples  of  mon- 
strosity. And  in  such  degraded  countenance,  instead  of  the 
"human  face  divine,"  one  is  horrified  with  the  sight  of  a  figure 
akin  to  that  of  a  Medusa,  a  sight  which  inspires  the  beholder 
with  feelings  of  pity  and  disgust.  Scljiller  realized  this  when  he 
depicted  his  villain  Roller  with  a  deformed  nose.  If  the  subject 
of  calamity  be  one  who  is  compelled  to  earn  a  livelihood  by  labor, 


itBIXOPLASTY.  411 

he  will  find  most  doors  closed  against  him ;  so  that  life  becomes 
a  burden  to  him.  And  such  unfortunate  has  been  known  to  tire 
of  his  lot,  and  to  yield  to  the  impulse  to  drop  the  burdens  of  life 
by  suicide.  Besides  this  the  absence  of  the  external  nose,  with 
perhaps  disease  in  the  remaining  fragments,  and  the  accumula- 
tion of  sordes  or  septic  excreta  in  the  choanse,  infect  the  patient's 
breath  with  foul  odor,  so  that  both  nose  and  eye  of  those  about 
the  victim  are  constantly  offended.  The  absence  of  the  external 
nose  allows  air  laden  with  dust  to  pass  unimpeded  to  the  luno-s, 
and  to  cause  disease  there.  The  warming  function  of  the  normal 
nose  is  wanting,  and  hence  the  cold  air  directly  enters  the  lungs. 
The  voice  of  the  noseless  face  acquires  a  disagreeable  tone.  The 
sense  of  smell  is  weakened,  and  perhaps. lost;  and  as  the  nose  is  an 
intimate  ally  of  the  tongue,  it  happens  that  when  smell  is  lost,  taste 
is  much  impaired.  For  perfect  olfaction  a  complete  nasal  vesti- 
bule is  required.  The  current  of  air  must  transport  the  odorant 
particles  into  the  upper  nasal  chamber:  a  fact  j)roven  by  Beclard, 
who  found  that  when  the  air  is  conducted  into  the  lower  part  of 
the  nasal  passages,  any  fragrant  matters  which  it  may  contain 
are  not  perceived.  And  in  subjects  in  whom  the  nose  was  want- 
ing, the  power  of  olfaction  was  entirely  lost.  Hence,  as  seen,  the 
restoration  of  the  lost  nose  is  demanded,  not  only  to  overcome  a 
great  deformity,  but  to  aid  in  phonation,  respiration,  taste  and 
smell. 

The  restoration  of  the  lost  nose,  as  before  mentioned,  may  be 
from  structure  obtained  from  some  other  part  of  the  dermal 
surface  of  the  body,  which  is  directly  transplanted;  or  this  ma}^ 
be  from  the  arm  or  forehead,  with  temporary  retention  of  the 
pedicle,  or  the  repairing  material  may  be  from  the  cheek  on  each 
side,  with  permanent  retention  of  the  pedicle.  The  structure  is 
oftenest  taken  from  the  forehead. 

In  the  selection  of  the  repairing  material,  certain  conditions 
in  the  latter  are  demanded,  viz.,  that  it  have  an  ample  supply  of 
blood  furnished  through  the  pedicle,  and  that  tlie  material  used 
be  sound  in  structure.  As  a  rule,  tissue  which  is  j)artly  or  wliolly 
cicatricial,  should  not  be  used;  for  such  material  will  nearl}^ 
always  perish,  and  render  the  work  a  failure.  The  writer  has 
more  than  once  heard  the  plaintive  lament  of  some  operator  who 
has  met  with  a  signal  failure  through  using  cicatricial  tissue;  the 
whole  had  sloughed,  and  the  previous  deformity,  instead  of  being 
relieved,  had  been  added  to;  and  the-  writer  confesses  to  like 
chagrin  from  having  violated  the  rule  which  he  is  here  enjoining. 


412  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGHMORE. 

The  only  license  for  such  violation  would  be  in  cases  in  which 
none  other  than  cicatricial  tissue  existed,  and  the  scar  did  not 
reach  through  the  structure  to  be  transplanted,  or  had  existed  so 
long  that  the  part  liad  nearly  regained  its  normal  character.  Only 
in  sucli  conditions  should  one  venture  to  transplant  cicatricial 
structure.  It  should  have  been  stated  tliat  the  slougliing  of  the 
transposed  cicatricial  flap  is  but  a  part  of  the  ill  result;  there 
remains  whence  the  flap  was  lifted  an  open  ulcerating  wound, 
often  destined  to  baffle  all  efforts  at  closure,  for  an  interminable 
period.  Indeed,  a  disregard  of  this  rule  is  similar  in  result  to 
that  of  violating  a  kindred  injunction  familiar  to  most  readers, 
viz.,  the  rent  is  greater  than  before. 

The  part  utilized  must  have  an  amjde  supply  of  blood,  and 
hence  the  pedicle  sliould  contain  a  nutrient  artery  or  arterioles, 
and  the  flow  of  blood  should  not  be  impeded  through  this  by 
tension  or  pressure.  The  material  on  the  forehead  is  favorably 
situated  in  reference  to  blood  supply  through  the  frontal  artery, 
which,  emerging  from  the  orbit  above  the  inner  angle  of  the  eye, 
ascends  vertically  near  the  median  line.  An  exact  knowledge 
of  the  site  of  this  vessel  wliere  it  escapes  from  the  orbit  is  highly 
important;  as  given  by  Ilyrtl,  who  is  ever  exact  and  trustworthy 
ill  his  statements,  each  frontal  artery  lies  from  three  to  four  lines 
outside  of  the  median  line.  Hence  a  pedicle  of  which  one  side 
corresi)onds  to  the  median  line,  of  one-half  inch  breadth,  will 
include  at  least  one  of  the  arteries;  and  a  breadth  of  over  two- 
thirds  of  an  inch,  including  the  median  line,  will  contain  both 
vessels.  The  inclusion  of  both  vessels  might  furnish  too  much 
blood;  for,  according  to  Dieffenbach,  the  death  of  the  flap  may 
be  caused  by  excessive  congestion  of  the  part;  in  fact,  he,  perhaps 
the  greatest  of  plnstic  ojierators,  quite  neglected  the  vascular 
supply  and  made  the  pedicle  so  narrow  that  it  could  be  readily 
twisted.  Rhinoplastic  repair  is  oftenest  done  by  material  taken 
from  the  forehead,  and  the  modes  of  doing  this  will  next  be 
considered. 

The  work  will  commence  with  the  construction  of  a  model, 
to  which  tlie  new  nose  is  to  conform  in  size  and  outline;  such  a 
model  might  be  taken  from  a  nose  on  another  face;  yet  it  is 
oftener  made  from  wax,  India  rubber,  or  plaster  of  Paris.  On 
such  model,  adhesive  plaster  is  s})read,  and  the  outline  thus 
obtained.  Or  it  might  be  made  of  leather,  and  afterwards  this 
must  be  coated  with  diachylon,  or  other  adhesive  material.  In 
the  normal    face  the  length  of  the  nose  is  about  equal  to  the 


RHINOPLASTY. 


413 


Figure  6.  Exhibiting  rhinoplastic  procedui'e  by  means  of  a  vertical  flap 
taken  from  the  forehead  (from  '  'Dictionaire  Encyclopedique  des  Sciences  Med- 
icales!  Dechambre  et  Lereboullet). 

height  of  the  forehead ;  hence  the  guiding  superficial  model 
should  have  that  length.  But  as  material  for  forming  the  sep- 
tum will  be  required,  hence  the  model  must  extend  into  the 
hairy  scalp  for  one  inch,  which  should  be  shaven  at  that  point. 
In  this  work  the  contractile  property  of  the  skin  when  divided 
must  be  remembered,  and  due  allowance  for  the  same  be  calcu- 
lated. The  experiments  and  observations  of  Farabeuf  have 
shown  that  this  contractility  in  the  case  of  amputation  is  equal 


Figure  7.  Showing  Alquie's  rhinoplastic  method,  in  which  an  oblique  flap 
is  taken  from  left  side  of  the  forehead.  (Dictionaire  Encyclopedique  des  Sci- 
ences Medicales). 


414  MAXILLAKY    SIXUS,    OR    ANTRUM    OF    HIGHMORE. 

to  one  about  one-third  of  the  diameter  of  the  limb  which  is 
divided.  Hence  the  frontal  flap  should  be  made  at  least  one- 
third  longer  and  one-third  broader  than  tlie  nose  which  it  is 
designed  to  form.  In  the  directly  vertical  flap,  as  shown  in 
Figure  6,  unless  the  forehead  were  high,  it  would  not  be  possible 
to  extend  farther  upwards  without  entering  the  hairy  scalp;  and 
hence,  as  a  free  field  in  which  ample  range  w^ould  be  permitted 
to  the  operator,  the  plan  of  Alqui^  may  be  followed,  viz.,  to  con- 
struct an  oblique  flap  over  one  eye,  with  its  free  end  directed 
towards  one  of  the  temples,  as  is  shown  in  Figure  7.  To  assist  in 
twisting  the  flap,  one  of  the  terminal  incisions  below  should 
extend  further  downwards  than  the  other;  the  mode  of  doing 
this  will  be  understood  by  reference  to  Figure  7. 

The  retention  of  the  periosteum  along  with  the  flap  was  done 
by  Langenbeck,  wdth  the  hope  that  bone  might  thus  be  formed 
beneath  the  transj^lanted  flap,  and  that  thus  there  maybe  obtained 
an  osseous  framework  for  the  newly  constructed  nose.  From  the 
reports  of  those  who  have  thus  operated,  it  does  not  appear  that 
this  expectation  has  been  realized.  Others,  laboring  under  as 
great  a  fallacy,  have  not  removed  the  periosteum,  in  order  to 
spare  encephalic  trouble  which  might  result  from  the  exposure 
of  the  cranium. 

The  margins  of  the  flap  should  not  be  cut  perpendicularly, 
but  in  such  a  way  as  to  enlarge  the  surface  of  sutural  attach- 
ment; thus  coaptation  is  facilitated,  and  subsequent  vitality 
favored. 

Th-e  nasal  site  is  next  to  be  prepared  for  reception  of  the  flap. 
All  osseous  and  cartilaginous  structures  are  to  be  carefully  saved; 
for  upon  the  presence  or  absence  of  a  su^jporting  framework  will 
wholly  depend  the  excellence  of  result  in  the  work  done:  for  if 
the  bone  and  cartilages  are  absent,  the  newly  constructed  nose 
will  be  but  a  flattened  bridge  across  the  nasal  breach ;  but  if  there 
is  a  sustaining  skeleton  on  which  to  build,  the  newly  formed  part 
will  certainly  resemble,  if  it  does  not  represent,  a  nose.  The  mar- 
gins of  the  part  to  be  restored  are  to  be  trimmed  in  an  oblique 
direction,  so  as  to  present  a  surface  which  will  correspond  to  the 
broadened  edges  of  the  flap.  The  summits  of  the  remaining 
cartilage  and  bones  must  be  paired  so  as  to  present  a  raw  surface, 
which  may  cohere  to  the  under  surface  of  the  flap. 

The  Avork  having  advanced  to  this  stage  before  adjusting  the 
flap  to  its  site,  the  operator  will  wait  until  he  has  controlled  all 
bleeding;  this  done,  he  will  next  give  the  pedicle  such  a  form 


KHIXOPLASTY. 


415 


that  its  torsion  will  be  facilitated  ;  for,  without  such  preparation, 
the  application  of  sutures  on  the  side  towards  which  the  flap  has 
been  twisted  will  be  difficult,  and  the  sutured  margins  will  be 
uneven,  and  become  still  more  so  when  swelling  occurs.  To  aid 
in  torsion,  Lisfranc  proposed  to  elongate  downwards  one  of  the 
incisions.  In  the  Indian  method  the  incisions  ended  below  at 
points  on  a  level  with  the  eyebrows.  Lisfranc  advised  to  carry 
the  cut  one-half  inch  farther  downwards  on  the  side  towards 
which  the  torsion  is  made.  Labat  and  Langenbeck  amended 
this  incision  by  carrying  the  cut  downwards  and  towards  the 
other  side.  For  example,  if  the  torsion  is  to  be  towards  the  left 
side,  the  left  incision  must  reach  downwards  a  half  inch  further 
than  the  right  one;  and  the  left  cut,  besides  being  made  longer, 
is  to  be  carried  towards  the  right,  until  it  reaches  or  has  slightly 
passed  the  median  line.  In  this  j^reliminary  preparation  for 
easily  twisting  the  flap,  the  vitality  of  the  latter  must  be  borne 
in  mind;  and  one  of  the  frontal  arteries  must  be  retained  intact 
in  the  pedicle.  The  method  of  Alcj^uie,  in  which  the  flap  is  taken 
from  over  one  of  the  eyes,  though  the  torsion  might  be  reduced 
from  180°  to  perhaps  120°,  yet  in  its  preparation  the  tw^o  frontal 
arteries  w^ould  be  severed,  and  the  upper  third  of  the  flap  would 
be  cut  off  from  any  direct  arterial  supply,  and  hence  its  vitality 
would  be  endangered.  As  seen,  the  problem  of  torsion  of  the 
pedicle  has  been  but  imperfectly  solved  ;  and  this  has  led  to  the 
attempt  to  use  the  flap  without  torsion,  as  will  be  seen  hereafter. 

In  the  methods  of  operating  described,  after  the  reversed  (over- 
turned) transposed  flap  had  formed  adhesions  to  its  new  site,  it 
w^as  customary  to  divide  the  pedicle;  and  the  result  was  that  the 
reformed  nose  contracted  into  a  very  unsatisfactory  shape.  To 
avoid  such  shrinking,  the  endeavor  has  been  made  to  dispense 
with  the  section,  and  to  so  dispose  of  the  pedicle  at  the  primary 
operation  that  it  would  be  less  prominent.  To  accomplish  this, 
Dieffenbach  made  a  vertical  incision  at  the  root  of  the  nose,  and 
placed  the  pedicle  in  this  sulcus,  and  applied  compression  on  the 
parts  so  as  to  cause  adherence.  Blandin,  to  accomplish  the  same, 
excised  the  surface  of  the  skin,  on  which  the  pedicle  is  to  lie. 
But  Velpeau  excised  the  pedicle,  converted  it  into  a  triangular 
form  and  placed  this  in  a  sulcus  which  he  had  made,  and  retained 
it  there  by  sutures.  The  plan  of  Blandin  or  Dieflenbach  is 
preferable. 

Instead  of  forming  the  sub-septum  from  frontal  integument, 
this  may  be  constructed  from  the  upper  lip,  as  has  been  hereto- 
fore described. 


41G  MAXILLARY    SINUS,    OR    ANTRUM    OF    HKiHMORE. 

In  case  the  septum  is  wanting,  the  transposed  frontal  flap 
would  rest  as  a  flattened  bridge  across  the  nasal  breach,  and,  at  best, 
be  nothing  more  than  a  caricature  of  a  nose.  To  improve  the 
condition  in  such  a  case,  Verneuil  has  conceived  the  thought  of 
doing  the  work  by  means  of  a  frontal  flap,  and  two  flaps  taken, 
one  on  eacli  side  of  the  nose.  A  frontal  flap  is  to  be  modeled  and 
brought  directly  down  on  the  breach  without  torsion;  that  is, the 
bleeding  surface  is  outside,  and  tlie  epiderm  directed  inwards. 
Then  from  each  side  a  flap  is  to  be  uplifted,  and  the  two  are  to 
be  drawn  across  the  raw  surface  of  the  frontal  flap,  and  fixed  there 
by  sutures.  In  this  way  the  wanting  nose  can  be  built  up  and 
given  a  greater  solidity  than  it  would  have  from  a  single  thick- 
ness of  transposed  structure.  The  pedicle  of  the  frontal  portion 
may  be  made  narrower  than  where  it  is  twisted. 

In  tliis  work  of  nasal  repair,  which  is  done  to  render  a  face 
less  repulsive  to  otlier  eyes,  it  must  be  ever  remembered  that  the 
subject  has  another  interest  in  tlie  matter,  viz.,  that  it  may  be 
provided  with  nostrils  through  which  he  can  breathe;  and  open- 
ings for  this  must  be  maintained.  For  this  purpose  tubular 
obturators  must  be  placed  in  the  new-formed  nostrils,  and  retained 
there  for  many  months.  Such  tubular  obturators  may  be  formed 
of  silver,  lead,  aluminum  or  of  India  rubber. 

Some  facts  should  be  mentioned  in  respect  to  tlie  newly  trans- 
planted material.  For  a  time,  its  temperature  is  lower  than  that 
of  the  surrounding  parts;  for  a  short  period  it  is  pale,  cold  and 
cadaver-like.  In  the  transplanted  structure,  in  regard  to  the 
alternate  ebbing  and  inflowing  of  blood,  and  the  ascent  and 
descent  of  temperature,  which  are  said  to  have  continued  for 
many  hours,  tlie  statements  of  Inmisch,  Coote,  and  others  are 
examples  of  careless  assertion  rather  than  of  accurate  observa- 
tion; for,  as  the  writer  has  often  witnessed,  the  circulation  is  soon 
established  in  the  part,  and  though  it  may  be  briefly  cyanoscd, 
yet  the  natural  color  returns  early,  and  occasionally  the  part 
becomes  temporarily  red  and  congested.  Excessive  congestion  is 
assigned  by  Dieff'enbach  as  the  usual  cause  of  death  of  the  trans- 
planted structure.  And  to  avert  sloughing,  where  the  part 
becomes  passively  surcharged  with  blood,  Dieff'enbach  scarifles 
the  swollen  part  and  thus  relieves  the  turgid  condition.  As  to 
the  dressing  of  the  part,  authorities  differ,  some  using  warm, 
others  cold  applications.  The  condition  of  the  part  should  guide 
in  the  matter;  in  the  early  stages,  before  the  circulation  has  been 
restored,  this  ought  to  be  favored  by  warm  dressings;  but  later, 


RHINOPLASTY.  417 

when  the  congestive  period  appears,  then  the  constrictive  action 
of  cold  dressings,  or  scarification,  may  be  resorted  to  as  means  of 
reduction. 

Tlie  sensation  of  the  transported  structure  will  be  lessened  and 
perverted  in  character;  for  nerves  have  been  severed,  and  those 
left  intact  are  altered  in  their  position  in  reference  to  the  surface 
of  the  body,  and  the  result  is  that,  when  the  new  nose  is  touched 
or  irritated,  the  sensation  awakened  is  referred  to  the  forehead. 
And  this  error  of  place  continues  for  a  long  period,  and  whether 
it  is  finally  dissipated  by  education  and  experience,  the  writer 
has  not  been  able  to  verify  by  observation.  From  the  fact  that 
after  amputation  of  limbs,  a  similar  error  of  sensation  exists,  which 
finally  vanishes,  it  is  inferable  that  a  correction  finally  obtains  in 
case  of  the  new  formed  nose. 

The  condition  may  exist  in  which  the  septum  and  nasal  bones 
are  absent;  such  a  state  constitutes  the  highest  grade  of  nasal 
deformity;  and  what  is  quite  as  unfortunate,  plastic  surgery  has 
been  able  to  offer  the  unhappy  subject  only  slight  relief;  a 
revolting  deformity  has,  by  the  hand  of  rhinoplastic  art,  been 
exchanged  for  an  unsightly,  repulsive  substitute.  The  trans- 
ported structure,  lacking  median  and  lateral  support,  lies  flat  over 
the  breach.  The  best  that  can  be  said  of  such  a  state  is  that  it  is 
better  than  no  nose.  Perhaps,  through  combining  the  untwisted 
frontal  flap  with  lateral  flaps  from  the  cheek  adjacent,  the  flattened 
structure  could  be  made  more  prominent;  but  the  new  struc- 
ture would  not  be  relieved  of  repulsive  clumsiness.  In  such  a  case 
in  which  there  was  a  total  lack  of  the  parts  which  sustain  the  nose, 
resulting  from  the  misfortunes  of  misguided  passion,  the  writer, 
in  1864,  operated  as  follows:  A  plate  of  gold  was  prepared,  in  the 
form  of  a  parallelogram,  of  dimensions  sufficient  to  replace  the 
absent  nasal  bones.  The  plate  was  so  thin  that  it  could  easily  be 
molded  into  an  arched  form.  The  site  was  prepared  by  trimming 
the  uneven  margins  and  then  lifting  up  the  integument  so  as  to 
form  lateral  flaps,  of  which  the  anterior  margins  were  equal  to 
the  length  of  the  nose  which  was  to  be  formed.  Such  a  flap  was 
dissected  up  from  the  subjacent  parts  on  each  side.  Next,  a  frontal 
flap  was  traced  out  and  lifted  from  the  bone.  The  plate  of  gold 
was  next  put  into  its  destined  position,  with  its  marginal  sides  un- 
derneath the  lateral  flaps.  The  flap  from  the  forehead  was  placed 
without  torsion  on  the  plate  and  beneath  the  marginal  flaps, 
which  covered  with  their  raw  surface  a  portion  of  the  frontal 
flap.     No  septum  was  formed,  as  it  was  deemed  better  to  defer 


418  .MAXILJ.AKY    SINUS,    OR    ANTRUM    OF    HIOHMORE. 

this  until  tlie  remaining  work  had  been  tested.  When  cicatriza- 
tion had  ended,  the  band  of  scar  along  the  dorsum  of  the  nose 
did  not  present  as  ill  an  aspect  as  liad  been  feared.  But  the 
patient,  whose  morale  was  below  par,  finally  became  impatient  of 
the  pain  caused  by  the  contraction  of  the  cicatrizing  structure, 
and  after  three  months  begged  to  have  the  metallic  support 
removed,  which  being  done,  the  unsupported  parts  sank  almost 
to  a  level  with  the  j^arts  around. 

The  experience  of  this  case  showed  that  in  a  patient  more 
tolerant  and  docile  to  surgical  management,  with  some  modifica- 
tion of  the  work,  the  ])lan  here  described  might  be  employed  to 
advantage  in  those  cases  in  which  the  osseous  and  cartilaginous 
framework  of  the  nose  is  absent.  The  frontal  flap  should  have 
been  provided  with  material  for  forming  a  sub-septum;  the  mar- 
gins should  have  been  obliquely  beveled  on  the  dermal  side,  and 
the  flap  turned  by  torsion;  the  beveled  edges  should  then  be 
placed  beneath  the  loosened  margins  on  each  side  of  the  nose. 
The  frontal  flap  should  be  so  large  that  it  will  require  no  addi- 
tion to  it  from  the  contiguous  structures  of  the  cheeks.  A  pro- 
cedure thus  carried  out  would,  in  a  great  degree,  avoid  the  pain 
from  contracting  cicatrization.  If  nasal  reconstruction  were  thus 
done,  the  part  would  be  provided  with  an  enduring  framework, 
which  w'ould  defy  change  from  time  or  disease;  and,  according 
to  the  Twelve  Tables  of  the  old  Roman  law,  which  forbade  the 
cremation  of  gold  which  had  been  used  to  fasten  the  teeth,  so 
the  gold  used  in  nasal  repair  might  at  death  be  rescued  and 
made  to  do  duty  again  by  some  conservative  nasifex. 

It  is  in  order  to  next  consider  the  method  of  nasal  construction 
in  which  the  restoration  is  done  w'ith  material  taken  from  the 
arm,  known  as  the  Italian  or  Talicotian  procedure.  This  method 
appears  to  have  been  used  particularly  in  those  cases  in  which 
the  supporting  framework  of  the  nose  had  been  lost.  This  opera- 
tion, as  done  by  the  Italian  surgeon  Tagliacozzi,  consisted  of  a 
series  of  acts,  which  required  from  six  to  eight  weeks  for  their 
completion. 

Taliacotius,  as  he  latinizes  his  name,  seems  to  have  dreaded 
that  his  material  might  die,  and  to  avoid  this  he  subjected  the 
part  to  be  used  to  a  preliminary  preparation;  during  a  consider- 
able period  he  treated  the  skin  over  the  biceps  muscle  with 
rough  friction  and  flagellation  until  the  structure  was  hardened 
and  resembled  that  of  the  elbow.  The  integument  being  thus 
altered   until  it  no   longer  resembled  the  skin  of  the  arm,  the 


RHINOPLASTY. 


419 


operator  seized  and  lifted  up  a  fold  of  it  with  forceps,  and  cut 
this  so  that  there  was  formed  a  flap  with  free  end  directed 
upwards,  and  pedicle  attached  some  two  inches  above  the  cubital 
flexure.  This  flap  in  its  dimensions  is  double  the  size  of  the 
future  nose.  The  wound  made  behind  the  flap  is  closed  by 
sutures,  and  the  bleeding  surface  of  the  flap  in  extended  position 
is  covered  with  ointments,  or  material  which  will  promote  sup- 
puration. Prior  to  the  operation,  during  a  few  days,  the  arm  is 
to  be  trainee!  to  a  position  in  which,  the  limb  being  uplifted  and 
the  elbow  fixed,  the  front  surface  of  the  upper  arm  is  brought 
near  the  nose  and  retained  there.  To  maintain  this  tiresome 
posture  the  patient  must  wear  a  hood-like  head-dress,  which  is  a 
continuation  of  the  outer  coat  of  the  chest.  With  such  a  dress 
the  arm,  with  the  aid  of  attached  straps  and  buckles,  can  be  con- 


FiGURE  8.     Illustrating  the  Talicotian  method  of  rhinoplasty. 

fined  in  the  position  mehtioned.  Such  a  position  should  be 
maintained  for  not  less  than  two  days  prior  to  the  preparation  of 
the  flap.  The  position,  as  well  as  the  means  of  fixing  the  arm,  is 
seen  in  the  annexed  figure.  The  work  of  fixing  the  limb  has 
been  done  by  means  of  adhesive  plaster;  this  plan,  however,  is 
less  trustworthy.  After  the  flap  had  suppurated,  Tagliacozzi, 
having  trimmed  the  nasal  breach,  to  which  the  former  is  to  be 
applied,  next  proceeded  to  apply  a  prepared  model  of  the 
intended  nose  to  the  flap,  and  trimmed  from  the  latter  the  surplus 
material,  and  fixed  the  flap  to  the  nasal  breach  by  marginal 
sutures.  The  arm  must  still  be  maintained  applied  to  the  head, 
and  retained  there  by  the  contentive  means  described,  for  at  least 
twenty  days.  The  flap  thus  adheres  by  its  summit  and  borders 
to  tlie  nasal  site;  the  pedicle  remains  adherent  to  the  arm. 


420  MAXILLARY    SIMS,    OK    ANTRUM    OF    HIGHMORE. 

After  twenty  days.  Tagliacozzi  divided  with  scissors  the  ped- 
icle, which  reached  well  down  towards  the  mouth;  from  the  lower 
border  of  the  flap-like  structure,  the  operator  next  ])roceeds  to 
construct  o[)enings  for  the  naics,  and  also  the  sub-septum.  To 
form  the  nares,  the  skin  is  infolded,  and  the  orilices  are  main- 
tained open  by  tubes  placed  in  them. 

Griefe  performed  the  Talicotian  operation  with  some  modifi- 
cations; but  instead  of  a  flap  from  the  humeral  region,  he  took 
the  reparative  material  from  the  front  of  the  forearm.  Instead 
of  letting  the  uplifted  flap  pass  through  the  suppurative  stage, 
he  used  it  at  once.  A  pasteboard  model  of  the  nose  having  been 
prepared,  this  was  laid  on  the  forearm,  and  the  flap  incised,  ele- 
vated, and  at  once  united  to  the  recently  trimmed  surface  of  the 
nasal  site.  The  arm  was  maintained  bound  to  the  head  for  three 
weeks,  when  the  pedicle  was  severed,  and  a  sub-septum  and 
nares  coiL^^tructed.  Griefe  thus  operated  six  times,  with  success- 
ful result  in  five  jiatients.  It  has  been  done  by  a  few  other  sur- 
geons; the  result,  as  recorded,  is  satisfactory  for  a  few  weeks,  but 
some  months  later  the  i)art  becomes  less  by  atrophy,  so  that,  by 
its  smallness,  it  contrasts  with  the  remainder  of  the  face.  To 
compensate  the  future  diminution,  the  part  should,  at  first,  have 
proportions  abnormalh'  large;  and,  as  the  brachial  field  of  supply 
is  abundant,  ample  provision  for  shrinkage  might  readily  be 
made. 

Talicotian  rhinoplasty,  or  that  done  by  the  use  of  transplan- 
tation of  material  from  the  arm,  is  in  less  favor  than  is  the  pro- 
cedure in  which  pediculated  flaps  from  parts  contiguous  are  used; 
yet  the  former  may  be  used  in  cases  in  which  the  latter  annot 
be  pursued.  For  exam})le,  where  the  frontal  derm  is  so  scarred 
that  its  vitality  is  lowered,  or  its  surface  is  greatly  disfigured,  then 
brachial  transplantation  is  preferable.  Again,  the  patient  may 
object  to  having  an  indelible  mark  set  in  his  forehead,  which,  as 
a  telltale,  would  reveal  his  misfortunes;-  here,  again,  material 
from  the  arm  might  be  employed  for  the  re{)air. 

Partial  Nasal  Repair. — Partial  restoration  of  the  nose  may  be 
demanded  in  case  of  loss  of  the  alar  margin  of  the  nostril,  or  of 
the  side  of  the  nose  including  the  alar  margin,  or  of  the  tip  or 
lobule;  and  finally  a  sunken  condition  of  saddle-seat  shape  may 
solicit  surgical  aid.  And  the  work  of  restoration  may  be  required 
on  both  sides  or  on  one  side  only. 

In  each  of  these  cases  the  material  for  closure  is  taken  from  a 
surface  that  is  contiguous,  viz.,  from  tlie  forehead,  nose  itself, 


DEFECTS    FROM    LOSS    OF    SIDE    OF    NOSE.  v        421 

cheek,  or  upper  lip.  In  fact,  in  the 'selection  of  the  material  for 
replacement,  the  rule  should  be  to  take  it  where  it  is  most  readily 
accessible,  and  where  its  employment  will  cause  the  least  marring 
of  the  patient's  face.  And  these  conditions  are  generally  best 
fulfilled  by  choosing  material  from  intact  derm,  which  may  be 
on  the  upper  part  of  the  nose,  or  from  the  adjacent  cheek. 

Alar  Marginal  Defect. —  To  repair  this  breach,  after  trimming 
the  margins  of  the  defect,  map  out  and  uplift  a  pedicled  flap  from 
the  adjacent  derm  of  the  cheek;  and  as  this  replacing  material 
must  be  swung,  or  revolved,  into  its  destined  site,  it  should  be  so 
situated  that  it  can  be  moved  into  place  through  the  shortest 
circuit.  If  the  flap  be  so  placed  that  its  free  or  distal  border  is 
directed  towards  the  outer  angle  of  the  eye,  it  can  be  shifted  to 
its  intended  site  by  passing  through  an  arc  of  ninety  degrees. 
But  if  this  border  be  directed  towards  the  inner  angle  of  the  eye, 
the  movement  of  transposition  will  be  done  through  an  arc  of 
not  more  than  forty-five  degrees.  And  the  same  would  be  true 
if  the  material  be  taken  from  the  upper  lip.  It  is  better  to  take 
the  material  from  the  inner  portion  of  the  cheek:  that  is,  from 
the  derm  alongside  of  the  nose.  This  flap  must  exceed,  in  length 
and  breadth,  the  breach  which  it  is  to  fill;  and  allowance  should 
be  made  of  not  less  than  two  lines  in  each  direction,  for  subse- 
quent contraction.  Should  ample  allowance  for  diminution  not 
be  made,  and  the  border  rise  above  the  normal  level,  the  patient 
will  deem  himself  but  imperfectly  paid  for  his  pains.  The  flap 
with  derm  outside  is  placed  in  position  and  retained  there  by 
metallic  sutures,  which  should  remain  in  place  for  a  week  at  least. 
It  is  seldom  that  an  obturating  tube  is  required.  The  wound 
remaining  in  the  cheek  must  also  be  carefully  closed  by  metallic 
sutures.  In  the  closure  of  this  wound  the  movable  part  of  the 
nose  is  usually  deflected  to  that  side  by  the  traction  made  on  it. 
Such  lateral  deflection  gradually  v.anishes  through  the  structures 
of  the  cheek  stretching  or  sliding  towards  the  nose. 

Defects  from  Loss  of  the  Side  of  the  Nose  including  the  Alar  Mar- 
gin.— For  the  repair  of  this  extensive  breach,  material  in  the  form 
of  a  pedicled  flap,  might  be  found  in  the  contiguous  cheek;  and 
in  such  case  tlie technical  steps,  or  acts,  would  be  similar  to  those 
above  described  for  the  repair  of  defective  alar  margin.  If  the 
defect  were  not  extensive,  the  repairing  material  might  be  ob- 
tained from  the  upper  part  of  the  nose. 

Denonvilliers  repaired  the  breach  by  means  of  a  triangular 
flap  which  was  attached  at  the   root  of  the  nose,  and  liad  its 


422  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGHMORE. 

movable  border  lying  on  the  cheek.  Nelaton  used  for  the  purpose 
a  four-sided  flap,  of  which  the  pedicle  was  also  attached  at  the 
root  of  tlie  nose.  In  the  work  reported  thus  done,  there  was 
subsequent  retraction  of  the  alar  border. 

In  case  the  defect  should  be  but  a  small  opening  through  the 
side  of  the  nares,  closure  might  be  done  by  sliding  or  twisting  a 
small  flap  into  the  breach.  Or  the  metliod  wliich  Celsus  recom- 
mends for  the  closure  of  openings  in  the  ear  might  be  adopted. 
Celsus  writes:  "If  the  opening  bo  large,  as  is  wont  to  be  the  case 
in  those  wliose  ears  have  borne  weights  greater  than  they  could 
bear,  then  one  should  make  a  long  incision  superiorly;  and  hav- 
ing made  the  borders  (of  the  opening)  raw  with  a  scalpel,  then 
close  by  suture;  and  over  the  wound  a  medicament  must  be 
placed,  whieli  would  cause  union.  The  plan  here  indicated  is 
plainly  to  trim  the  borders  of  the  defect  and  elongate  this  by 
incising,  so  that  the  sides  could  be  brought  together.  By  sucli  a 
procedure,  openings  through  the  sides  of  the  nose  might  be  closed. 
If  closure  could  thus  be  done,  less  scarring  would  result  than 
would  occur  from  repair  through  borrowed  material. 

In  slight  defect  of  the  alar  margin,  Dieffenbach  resorted  to 
the  novel  procedure  of  trimming  off  the  wing  on  the  opposite 
side,  so  that  the  two  sides  would  be  of  corresponding  length. 
Though  the  sides  would  thus  be  made  symmetrical,  yet  the  comi- 
cal appearance  which  would  be  given  the  nose  by  such  retrench- 
ment, would  be  a  great  remove  from  cosmetic  improvement; 
some  one  compares  such  a  nose  to  that  of  a  cat. 

Repair  of  nasal  structure  is  sometimes  demanded  through 
depression  of  the  middle  portion  of  the  dorsal  ridge  in  which 
the  part  presents  a  saddle-seat  incurvation.  This  may  have,  as 
origin,  a  lesion  in  which  a  portion  of  the  nose  has  been  destroyed 
by  injury;  the  causal  agency  is  far  more  frequently  traceable  to 
a  constitutional  disease,  such  as  scrofula  or  syphilis,  in  which  the 
nasal  bones  necrosing,  the  supporting  skeleton  of  the  nose  is  lost, 
and  the  nose  sinks  at  its  middle.  The  lobular  part,  or  lower 
third,  of  the  nose  maintains  its  position  in  some  cases,  since  its 
cartilaginous  supports  remain  intact;  yet  not  unfrequently  the 
ulcerative  disease  reaches  and  attacks  the  cartilage,  so  that  the 
lobule  sinks,  and  recedes  into  the  upper  portion:  that  is,  the  lob- 
ular portion  is  received  in  the  upper  portion  similnr  to  telescopic 
ensheathing.  This  invaginated  deformity  is  much  more  difficult 
to  rectify  than  tl)at  in  which  the  lobule  is  in  its  natural  site,  and 
the  means  to  be  pursued  in  repair  differ  in  the  two  cases. 


DEFECTS    FROM    LOSS    OF    SIDE    OF    XOSE.  423 

Where  the  deformity  has  arisen  from  a  wound  in  which  a 
section  of  the  nasal  dorsum  was  destroyed,  and  the  remainder  of 
the  nose  is  intact,  then  repairs  might  be  done  by  means  of 
material  obtained  on  the  forehead,  root  of  the  nose,  adjacent 
cheek,  or  from  the  palm  of  the  hand.  When  done  by  means  of 
a  pedicled  flap  obtained  from  a  contiguous  surface,  the  work  is 
similar  to  that  which  has  been  described  for  restoration  of  the 
entirety,  or  side  of  the  nose.  Should  the  contiguous  material 
not  be  suitable  for  the  repair,  then  a  procedure  cognate  to  the 
Taliacotian  might  be  done,  in  which  a  flap  is  to  be  dissected  from 
the  palm  of  the  hand,  and  this  being  sutured  to  the  trimmed 
edges  of  the  defect,  the  hand  is  to  be  fixed  on  the  nose,  and  im- 
movably held  there  by  contentive  appliance,  in  which  the  hand 
is  immobilized;  and  then  the  arm  must  be  bound  against  a  sup- 
port placed  between  the  limb  and  the  side  of  the  chest. 

A  small  breach  in  the  dorsum  of  the  nose  from  traumatic 
cause  was  rectified  by  Reid  by  means  of  flaps  uplifted  on  each 
side  of  the  nose.  Each  flap  was  formed  by  means  of  two  lateral 
incisions,  which  were  four-fifths  of  an  inch  apart  at  the  base,  and 
two-fifths  of  an  inch  apart  above.  Next,  through  the  nostril  the 
septum  was  cut  from  the  structures  above,  so  that  the  parts  could 
be  lifted  into  proper  position,  in  which  they  were  retained  by 
means  of  pins.  These  pins  are  made  to  traverse  plates  of  lead 
laid  on  each  side,  so  disposed  as  to  maintain  the  nose  in  normal 
form  and  position.     Place  tampons  in  the  nostrils. 

Diefl'enbacli,  and  after  him  Malgaigne,  in  cases  in  which  the 
osseous  framework  had  been  destroyed  by  scrofula  or  syphilis,  so 
loosened  the  nose  from  the  face  6y  incisions  made  at  the  sides 
and  underneath,  that  the  movable  parts  can  be  molded  into  some- 
thing like  natural  form.  The  work  as  done  by  Malgaigne  is  de- 
scribed by  him  as  follows:  "The  wings  of  the  nose  were  separated 
from  the  cheeks  and  upper  lip;  the  loosened  lower  part  was  still 
further  detached  by  dissecting  the  soft  j)arts  from  the  nasal  bones 
at  the  root  of  the  nose,  as  far  as  the  frontal  bones;  also  the  upper 
lip  was  detached  from  the  apper  jaw.  After  this  work,  the  nose 
could  be  raised  and  modeled  into  form,  and  retained  so  by  long 
pins  which  were  passed  transversely  through  the  parts ;  the  heads 
and  points  of  the  pins  w^ere  sheathed  with  corks.  To  still  further 
hold  and  retain  the  nose  in  place,  adhesive  strips  and  collodion 
were  used;  and  silver  tubes  were  afterwards  worn  In  the  nostrils." 

To  restore  form  to  a  sunken  nose,  Konig  in  1886  operated  as 
follows:  A  transverse  cut  was  made  across  the  lower  part  of  the 


424  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGHMORE. 

nose;  through  tliis  cut  the  nasal  wings  were  dissected  up  and  so 
loosened  tliat  the  nose  could  be  reduced  to  something  like  the 
normal  form.  Next  a  long  flap  of  rectangular  shape  was  formed 
on  the  forehead,  and  was  detached  from  the  frontal  bone  along 
with  the  periosteum  and  the  outer  layer  of  the  bone.  Thus  there 
was  formed  a  cutaneous  periosteo-osseous  flap,  which  was  turned 
downwards  with  the  dermal  side  inwards  and  the  wounded  sur- 
face outwards.  This  flap  is  then  slightly  sutured  to  the  adjacent 
raw  edges  of  the  transverse  wound  previously  made  on  the  nose. 
The  next  step  was  to  form  a  similar  flap  of  smaller  size  on  the 
right  side  of  the  forehead,  which  is  to  be  turned  downwards  by 
means  of  torsion,  so  that  the  raw  surface  will  be  directed  inwards. 
This  flap  is  superposed  on  the  other  so  that  the  raw  surface  may 
cohere.  Thus  a  long  framework  was  obtained  which  afterwards 
remained  as  solid  material.  Konig  reconstructed  four  noses 
according  to  the  plan  here  described ;  they  had,  however,  the  fault 
of  being  too  thick  at  the  root:  they  were  "too  Grecian."  that  is, 
the  forehead  passed  into  the  no.'^e  with  too  little  incurvation  at 
the  root  of  the  nose.  Yet  this  defect  was  capable  of  some  improve- 
ment afterwards. 

We  will  next  treat  of  those  cases  in  which  the  surgeon  is 
compelled  to  remove  a  portion  or  the  whole  of  the  nose,  on 
account  of  some  malignant  disease.  Should  the  extirpation  be 
followed  by  immediate  repair,  or  should  this  be  delayed  to  deter- 
mine whether  recurrence  of  the  disease  will  ensue?  Authority 
differs  here.  Should  tlie  work  of  restoration  be  done  at  once,  and 
the  disease  return,  it  has  been  repeatedly  observed  that  the 
disease  attacked  the  transplanted  material.  The  proper  rule  of 
guidance  in  such  cases  seems  to  be  that  if  the  growth  can  be 
thoroughly  removed,  plastic  repair  should  immediately  be 
attempted.  Proof  that  the  diseased  structure  has  been  wholly 
removed  would  exist  where  the  lines  of  excision  had  passed  at 
least  four  lines  beyond  all  infiltrated  or  affected  tissue.  And, 
further,  should  the  disease  return  and  invade  the  tissue  used  for 
repair,  the  patient  wouLl  have  had  some  advantage  through  tem- 
porary suspension  of  both  his  disease  and  the  deformity  conse- 
quent on  its  removal.  Hence,in  a  i)atient  whosenose  is  attacked 
by  sarcoma,  epithelioma,  and  forms  of  cancer  other  than  encej)h- 
aloid  and  melanotic,  the  disease  should  be  extirpated,  and  plastic 
restoration  at  once  be  done,  from  the  lateral  structures  if  possible-, 
and  in  absence  of  material  there,  seek  it  on  the  forehead  or  on 
the  arm. 


DEFECTS    FROM    LOSS    OF    SIDE    OF    NOSE.  425 

There  are  cases  in  which  it  is  impossible  to  repair  the  wanting 
nose  by  any  of  the  procedures  practiced  in  rhinoplastic  surgery; 
or  tlie  performance  of  any  such  operation  may  not  be  advisable, 
owing  to  the  existence  of  some  disease  of  the  part  which  cannot 
be  eradicated,  without  too  extensive  destruction  of  the  parts. 
Examj)les  of  the  former  are  those  cases  in  which  the  face  has 
been  nearly  destroyed  by  violence;  or  the  face  of  a  patient  in 
which  the  field  whence  reparative  material  is  obtained  is  occupied 
by  a  cicatrix.  An  example  of  uncured  or  progressing  disease, 
forbidding  rhinoplastic  closure,  is  where  lupus,  rodent  ulcer, 
epithelioma  or  tertiary  syphilis  is  laying  waste  or  has  destroyed 
the  deeper  structures  of  the  nose;  a  field  where  such  invader 
having  intrenched  himself  tolerates  no  cooperative  occupancy. 

Prothetic  appliance  employed  to  conceal  partial  or  complete 
loss  of  the  nose  is  first  mentioned  by  Par^.  Various  materials 
have  been  used  for  the  construction  of  the  artificial  nose:  namely, 
it  has  been  made  of  light  w^ood,  of  gutta  percha,  vulcanized 
rubber,  of  lead,  tin,  silver  and  aluminum.  The  art  of  the  man- 
ufacturer has  been  mainly  occupied  in  devising  that  which  will 
deceive  the  eye  of  the  beholder;  that  the  false  nose  will  be  so 
cunningly  contrived  that  the  falsity  will  not  be  revealed;  a  coun- 
terfeit which  W'ill  impose  for  the  genuine.  To  accomplish  this, 
attention  must  be  directed  to  the  form,  color  and  retention  of  the 
device  in  its  destined  site. 

The  form  of  the  artificial  nose  is  readily  attained;  and  since 
it  would  be  difficult  to  select  a  type  which  would  content  all 
eyes,  hence  some  deviation  in  outline  is  tolerable.  The  hue  or 
tint  of  the  skin  is  easily  imitated,  especially  in  a  case  in  which 
non-metallic  material  is  employed;  but  if  the  material  be  silver 
or  aluminum,  the  metallic  appearance  cannot  be  disguised  by 
simply  painting  it;  the  object,  however,  can  be  attained,  as 
Charrierehas  done,  by  first  covering  the  metal  with  India  rubber; 
or  the  nose  might  be  wholly  constructed  of  this  latter  material. 
The  lightness  of  aluminum  gives  it  an  advantage  over  lead  or 
silver.  An  important  need  of  such  appliance  is  that  it  be  held  in 
position,  and,  if  possible,  that  this  be  done  by  means  which  escape 
observation.  If  the  entire  nose  be  replaced,  the  substituted  device 
may  be  kept  in  place  by  the  framework  or  bow  of  spectacles,  or 
the  same  can  be  attained  by  means  of  wire  springs  which  may 
pass  laterally  around  the  head;  or  the  spring  may  ascend  the 
forehead,  pass  over  the  head,  and  rest  claspingly  on  the  back  of 
the  head.  This  vertical  attachment  has  the  objection  of  being 
28 


426  MAXILLARY    SINUS,    OR    ANTRUM    OF    HIGHMORE. 

constantly  visible.  It  is,  however,  an  effective  mode  of  retentive 
fixation;  vet,  for  manifest  reasons,  the  mode  of  retention  by  the 
aid  of  spectacles  is  the  more  satisfactory  one. 

To  procure  a  mould  of  the  site  to  which  the  artificial  part  is  to 
be  attached,  first  plug  the  nostrils  and  cover  the  eyes;  lay  over 
the  site  some  thin  linen  or  cotton  cloth,  and  again  on  this  place 
and  mould  to  the  adjacent  parts  a  thickness  of  pasteboard  of 
nasal  form ;  now  slightly  lift  the  pasteboard,  and  while  the 
patient  is  leaning  forward,  pour  beneath  the  pasteboard  liquid 
gypsum,  which  hardening  forms  an  exact  cast  of  the  parts  beiiind. 

The  fabricated  nose  has  been  held  in  position  by  being 
attached  to  sponge  which  is  pushed  into  the  nostrils;  the  odor 
that  soon  proceeds  from  the  sponge  will  finally  disgust  lie  patient 
with  such  appliance.  A  more  successful  means  of  "fixation  is  by 
means  of  some  adhesive  composition  or  cement;  for  this  gum- 
shellac  may  be  employed. 

Along  with  the  loss  of  the  nose  there  may  coexist  defect  of  the 
lips  and  alveolar  process  of  the  upper  jaw.  In  such  cases,  along 
with  the  replacing  nose  there  might  be  associated  an  obturator  to 
close  the  defect  in  the  jaw.  And  the  ingenuity  of  the  artisan 
might  connect  the  nasal  portion  with  the  labial,  alveolar  or 
palatal  supplement.  The  connecting  means  may  be  wire  so 
placed  as  to  be  concealed;  namely,  from  the  inner  or  hidden 
surface  of  the  nasal  portion,  the  wire  might  pass  through  the 
maxillary  breach  and  be  joined  to  the  part  situated  within  the 
mouth. 

Cases  again  may  occur  in  which  a  replacement  of  a  portion 
of  the  defect  may  be  effected  by  some  plastic  procedure,  in  which 
structure  adjacent  is  utilized  for  the  work  of  closure. 


CHAPTER  XI. 


THE    ELEMENTS    OV   PLASTIC    SURGERY. 

Success  in  operative  work  within  the  domain  of  plastic  sur- 
gery is  only  to  be  reached  by  hiin  who  is  familiar  with  certain 
mechanical  principles,  and  who  is  guided  by  these  in  planning  as 
well  as  in  the  execution  of  his  work.  To  trust  to  the  eye,  and  to 
the  inspiration  of  the  moment,  may  answer  for  him  who  has  had 
much  practical  experience  in  such  matter,  yet  for  one  who  has 
not  had  such  discipline,  trusting  to  the  moment  for  lucky 
guidance  will  usually  end  in  an  unsatisfactory  result.  As  the 
navigator  who  is  compassless  might  reach  a  hundred  ports 
rather  than  the  intended  one,  so  the  plastic  surgeon  relying  on 
fortunate  chance  and  a  mechanical  eye  must  often  stray  far  from 
correct  lines,  A  little  geometry  will  add  to  the  accuracy  of 
the  scalpel  in  its  tasks  of  plastic  repair.  Lines  must  be  drawn  in 
accordance  with  premeditated  study  and  plan,  in  order  that  any 
degree  of  excellence  shall  mark  the  completed  work;  and  in  this, 
due  consideration  must  be  given  to  the  site,  inch'nation  and 
outline  of  the  part  to  be  repaired.  And,  also,  most  attentive 
study  must  be  given  to  the  selection  of  material  for  repair,  viz., 
where  such  material  is  most  accessible,  can  best  be  spared,  and, 
above  all,  that  its  situation  is  such  that  it  can  readily  be  shifted, 
or  moved  to  its  intended  site. 

In  the  consideration  of  rhinoplasty  glimpses  have  been  given 
of  the  points  here  referred  to;  a  more  systematic  elucidation  of 
them  will  now  be  presented. 

A  plastic  operation  may  be  defined  to  be  a  procedure  by 
which  a  breach  of  surface  may  be  closed  or  repaired;  or  an 
upheaved  or  irregular  surface  is  replaced  by  a  smooth  one;  or, 
finally,  plastic  surgery  has,  as  one  of  its  most  important  offices, 
the  restoration  of  parts  which  are  absent;  for  example,  con- 
genital defects,  or  which  have  been  lost  through  some  traumatic 

agency. 

(427) 


428  THE    ELEMENTS    OF    PLASTIC    SURGERY. 

The  work  of  repairing  a  defect  may  be  done  by  one  of  the 
following  methods:  (1)  By  adduction  or  sliding  and  partial  or 
complete  approximation  of  surfaces  which  lie  near  each  other; 
(2)  by  adduction  of  parts  which  lie  near  each  other,  after  detacli- 
ment  of  the  surface  from  structures  beneath,  with  which  it  is 
connected;  other  aids  in  such  approximative  sliding  are  sub- 
sidiary lateral  incisions;  (3)  by  means  of  a  replacing  pedicled 
flap  which  is  shifted  to  its  intended  site  by  revolving  it  through 
a  semicircle,  or  an  arc  of  the  same;  (4)  by  transplanting 
pedunculated  replacing  material  from  the  arm  or  hand  of  the 
patient,  or  from  the  body  of  another  individual.  And  as  a 
modification  of  this,  the  restoring  material  may  be  cut  off,  and 
without  sustaining  pedicle  be  transplanted  to  its  intended  loca- 
tion. The  most  of  plastic  surgery  is  done  by  one  of  the  first 
three  methods.  Where  the  defect  is  small,  closure  can  usually 
be  effected  by  the  first  method;  but  where  it  is  larger,  there  is 
often  needed  some  preliminary  preparation  of  the  surfaces  which 
are  to  be  approximated.  And  finally,  where  the  first  and  second 
methods  are  unsuited  to  do  the  closure,  a  pedicled  flap  taken 
from  a  surface  which  lies  iiiore  distant  may  be  prepared,  uplifted 
and  turned  around  into  the  defect. 

In  the  first  and  second  metliods,  as  subsidiary  work  to  aid  in 
closure,  the  defect  must  be  converted  into  a  figure,  the  outline  of 
which  will  favor  adductive  closure.  By  the  third  method,  it 
matters  not  what  outline  the  defect  may  have,  the  flap  of  replace- 
ment must  have  a  similar  one.  Hence  the  third  method  has 
special  advantages;  and,  besides,  the  fact  that  the  pedunculated 
flap  may  have  any  conceivable  outline,  it  may  be  taken  from  a 
surface  in  which  closure  can  easily  be  made,  and  the  resultant 
scar  will  not  be  conspicuous. 

As  stated,  in  the  first  and  second  methods  the  border  of  the 
defect  must  be  converted  into  a  figure  of  a  shape  that  will  favor 
adductive  approximation;  and  these  figures  are,  in  the  main, 
similar  to  those  employed  by  the  geometrician  in  the  solution 
of  his  theorems.  Classified  in  the  order  in  which  they  will  be 
presented  to  the  reader,  these  figures  are  the  circle,  semicircle, 
and  other  fractional  portion  of  a  circle,  the  ellipse  and  oval,  the 
triangle,  the  rectangle  or  parallelogram,  the  rhomboid  and  the 
lozenge.  These  figures,  diagramatically,  are  shown  in  the  sub- 
joined Figures  9,  10,  11,  12,  13,  14,  15,  16,  17,  18,  19,  20  and 
21, 


THE    ELEMENTS    OF    PLASTIC    SURGERY. 


429 


Figure  9.     Showing  the  circle.  Figure  10.     Showing  the  semicircle. 


Figure  11.       Exhibiting 
the  ellipse. 


Figure  12.     Showing  the  oval. 


Figure  13.     Showing  tri-      Figure  14.  Show- 
angle  of  equal  sides,  ing    triangle    wnth 

twQ  equal  sides. 


Figure  15.     Showing 
the  rectangle. 


Figure  16.     Representing  a  paral- 
lelogram. 


Figure  17.     Exhibiting  the  rhomboid. 


430 


THE  ELEMENTS  OF  PLASTIC  SURGERY. 


Figure  18.     Showing  rhomboid  slightly  lengthened. 


FiGiRE  19.    Illustrating  the  rhomboid  much  enlongated. 


Figure20.    Showin>r 


FiorKE21.     Showing  the  sector. 


The  First  Method,  or  that  of  immediate  Adduction. — In  this 
method,  of  the  figures  here  shown,  the  circle  and  the  oblong  rect- 
angle can  only  be  used  when  the  surface  of  the  defect  is  small. 
In  the  case  of  the  circle,  the  opposite  sides,  in  order  to  meet,  must 
be  carried  at  their  middle  point  through  half  the  diameter  of 
the  circle;  and  this  could  only  be  done  where  the  breach  to  be 
closed  is  small;  partial  closure,  however,  could  be  effected,  in 
which  the  circle  would  be  reduced  to  a  smaller  polygonal  figure, 


Ftgure  22.     Showing  closure  of  the  circle. 

as  sliown  ni  Figure  22.  In  case  of  a  rectangular  defect,  only  in  the 
event  of  the  surface  being  diminutive  could  the  opposite  sides  be 
approximated,  and  the  lines  of  suture  would  be  as  shown 
in  Figure  23. 


THE    FIRST   METHOD. 


43] 


Figure  23.     Showing  closure  of  the  parallelogram. 

The  oblong  figure  of  the  ellipse  and  oval  renders  them  easier  of 
closure  by  sliding  than  is  the  case  with  the  circle;  the  long  sides 
are  to  be  apposed,  and  the  result  will  be  a  straight  line. 

The  closure  of  a  triangular  defect  will  depend  on  the  figure  of 
the  triangle;  if  this  be  one  with  two  equal  sides  and  with  a  nar- 
row base,  juxtaposition  of  the  long  sides  is  easily  accomplished, 
with  the  result  of  sutural  lines  resembling  an  inverted  \.  Should 
the  triangular  defect  be  equilateral,  then  a  large  closure  could 
only  be  made  in  the  direction  of  the  angles,  and  the  result  would 
be  as  shown  in  Figure  24,  with   a   central   space   unclosed.     A 


Figure  24.     Showing  closure  of  the  equilateral  triangle. 

rhomboidal  defect  will  be  more  easily  closed,  proportionately  to 
the  obliquity  of  its  figure;  for  example,  the  same  amount  of 
space  in  Figure  17,  will  not  be  so  easily  closed  by  suture  as  that 
in  Figures  18  and  19,  of  which  the  line  of  closure  will  be  a  long 


i 1 


^ — I- 


oval. 


FiGUEE  25.     Showing  closure  of  a  rhomboid  space;  also  of  the  ellipse  and 


oblique  line;  for  a  defect  of  rhomboidal  figure  has  the  property 
that  as  the  obliquity  augments  the  long  sides  approach  nearer  to 
each  other.  A  figure  in  the  shape  of  a  lozenge,  which  is  similar 
to  two  isosceles  triangles  applied  base  to  base,  can  be  closed  by 
direct  sliding,  provided  the  open  surface  is  not  large. 


432  THE    ELEMENTS    OF    PLASTIC    SURGERY. 

A  fit^jure  which  is  compounded  of,  or  derived  from,  the  triangle 
is   that  shown  in  Figure  26;  and  occasionally  a  dermal  defect 


Figure  26.     Showing  a  triangle  with  Figure  27.     Showing  closure  of  this 

opening  in  base.  space. 

may  be  converted  into  this  form.  This  figure  consists  of  a  tri- 
angle of  two  equal  sides,  with  a  small  base  in  which  there  is  a 
reentrant  or  open  angle.  The  space  within  the  four  sides  repre- 
sents the  open  defect,  while  the  reentrant  angle  represents  sound 
tissue.  A  defect  in  such  form  can  easily  be  closed  by  adductive 
sliding.  The  point  a  can  be  pushed  still  further  inwards,  and 
included  in  sutures  which  approximate  the  long  sides.  Such  a 
figure  can  readily  be  closed;  the  sutural  line  is  shown  in  Figure 
27.  The  solid  structure  in  the  base  being  carried  upwards  will 
tend  to  support  the  structures  above.  This  plan  can  be  used  to 
correct  ectropic  eversion  of  the  lip  or  eyelid.  And  in  case  the 
defect  is  so  constituted  that  structure  can  be  preserved  as  a 
reentrant  angle  in  a  figure  which  is  otherwise  circular,  elliptical, 
oval  or  rectangular,  such  entering  angular  or  ovular  material 
will  facilitate  closure,  and  lessen  sutural  tension  at  one  point. 

In  the  first  method  of  closure  the  displacement  is  done  with- 
out any  detachment  of  the  skin,  which  is  moved  from  the  under- 
lying structures  to  which  it  is  adherent;  and  but  little  sliding 
can  be  done  without  subjecting  the  displaced  integument  to 
strain  or  tension.  The  small  vessels  which  maintain  the  nutri- 
tion of  the  skin  and  which  enter  it  from  underneath  and  from 
the  contiguous  derm,  are  stretched,  and  the  amount  of  blood  whict 
passes  through  these  vessels  is  greatly  diminished,  the  result  being 
that  the  shifted  skin  is  defectively  nourished,  and,  consequently, 
can  easily  die.  The  physical  law  obtains  here  that  when  a  tul>e 
is  doubled  in  its  length,  there  will  flow  through  it  but  half  the 
amount  of  fluid  which  passed  through  it  when  it  was  of  half  the 
length  ;  and  if  the  tube  be  reduced  to  one-half  of  its  previous 
diameter,  then  the  quantity  of  fluid  which  will  flow  through  it 


THE   SECOND    METHOD.  433 

will  be  sixteen  times  less  than  the  quantity  which  passed  before 
any  change  was  made  in  its  calibre.  It  is  evident  that  adductive 
approximation,  as  has  been  described  above,  both  elongates  the 
vessels  of  the  displaced  skin,  and  also  diminishes  the  calibre  of 
the  vessels;  and  the  result  is  a  diminished  supply  of  blood,  which 
can  easily  reach  a  limit  that  can  destroy  the  vitality  of  the  skin. 
And  if  the  skin  itself  does  not  die,  the  degree  of  tension  to  which 
the  skin  is  subjected  leads  to  its  being  cut  by  the  sutures,  and 
thus  the  healing  is  delayed  and  scarring  follows.  And  what  is 
more  to  be  feared,  when  the  sutures  cut,  they  fail  of  their  intended 
purpose,  viz.,  to  immobilize  the  shifted  surface  and  to  counteract 
retraction;  for  through  the  sutural  cutting,  the  adducted  parts  are 
permitted  to  retract,  and  this  may  endanger  the  work  done,  since 
the  approximated  parts  may  fall  asunder.  Sucli  result,  which 
often  attends  the  work  of  the  inexperienced,  soon  forcibly  teaches 
him  that  in  closure  by  direct  or  immediate  adduction,  severe 
straining  and  stretching  must  be  avoided. 

In  the  second  method,  to  facilitate  the  mobility  of  the  part 
which  is  to  be  shifted,  and  thus  by  diminishing  tension  to  favor 
the  vitality  of  the  transposed  structure,  there  must  be  done  some 
preliminary  preparation.  "When  the  defect  has  been  given  an 
oval,  elliptical,  circular,  triangular,  quadrangular  or  rhomboidal 
figure,  to  facilitate  adductive  approximation  of  the  marginal 
structure,  the  latter  may  be  dissected  from  the  subjacent  parts. 
In  this  dissection  the  subcutaneous  fascia  must  be  uplifted  with 
tlie  skin;  that  is,  the  fascia  and  derm  must  be  raised  as  one  layer. 
Sometimes  the  fascia  is  so  thin  that  it  is  nearly  indistinguishable, 
and  the  derm  seems  to  rest  on  the  adipose  layer  without  any 
tissue  being  interposed.  The  derm,  in  such  a  case,  though  it 
may  be  used,  yet  it  is  ill  suited  for  plastic  purpose;  and  when 
it  is  used,  a  thin  layer  of  adipose  tissue  should  be  detached  along 
with  the  derm.  This  subcutaneous  detachment  must  not  be  too 
extensive,  lest  in  the  hollow  space  created,  blood  may  accumulate, 
and  delay  or  prevent  healing.  If  the  subscision  should  extend 
farther  than  an  inch,  this  trouble  might  arise. 

Incisions  subsidiary  to  shifting  may  be  made  through  the 
skin;  and  such  incision  may  consist  of  cuts  which  are  a  continu- 
ation of  one  or  more  sides  of  the  figure  into  which  the  defect  has 
been  converted;  or  it  may  consist  of  an  incision  made  at  a  short 
distance  from  the  breach  to  be  closed  ;  thus  stretching  is  lessened, 
and  sliding  facilitated. 

These  preparatory  cuts,  as  adjuvants  in  closure,  are  mentioned 


434 


THE    ELEMENTS    OF    PLASTIC    SURGERY. 


by  Celsus  in  the  method  which  he  describes  for  closure  of  a 
qiiadranguUir  defect.  He  advised  to  coiitinne  laterally  the  upper 
and  lower  lines  of  the  four-sided  defect;  and  if  this  does  not 
suffice  for  closure,  then  a  crescentic  cut,  directed  towards  the 
wound,  is  to  be  cut  superficially  through  the  skin.  The  Celsian 
plan  of  closure  has  already  been  explained.  The  lateral  or  out- 
side accessory  incision  is  not  to  be  closed,  but  is  to  be  allowed  to 
heal  by  granulation;  and  this  scar  often  left  by  the  lateral  cut 
warns  the  surgeon  that  he  should  be  chary  of  its  use;  it  is  better 
to  effect  the  sliding  by  subjacent  detachment,  of  which  the  work 
will  remain  unseen.  The  open  lateral  cut  is  best  done  in  situa- 
tions in  which  the  resulting  scar  will  remain  invisible.  Cases  in 
which  it  may  be  employed  arc  those  in  which  large  breaches  have 
been  made  in  the  surface,  which  it  is  desirable  to  close  by  a 
tegumentary  covering.  And  as  the  site  of  such  operation  is 
often  hidden  by  the  subject's  clothing,  a  scar  from  lateral  sub- 
sidiary incision  becomes  unimportant. 

The  second  method  consists,  then,  of  closure  by  the  aid  of 
accessory  subscision,  continuation  of  existing  cuts  and  lateral 
incision;  and  it  may  be  used  for  the  effacement  of  any  breach 
which  has  been  converted  into  one  of  the  forms  before  mentioned. 
A  few  examples  of  its  application  will  here  follow.  A  triangular 
defect  may  be  treated  as  follow;:: — 


Figure  28.      Showing  two  parallelo- 
grams resting  on  the  same  base  c  d. 


Figure  29.  Showing 
result  after  closing  defect 
represented  in  Fig.  28. 


If  in  Figure  28  a  b  d  is  the  defect  to  be  closed,  let  the  side  a  6  be 
continued  to  e,  and  then  an  incision  be  carried  from  d  to  c,  and 
the  quadrangular  flap  b  d  eche  uplifted.  The  diagram  if  studied 
will  be  composed  of  the  parallelograms  abed  and  be  c  d,  which 
are  geometrically  equal  to  each  other,  since  they  rest  on  the  same 
base,  d  c,  and  lie  between  the  same  parallel  lines;  hence  the  right 
figure  can  be  slidden  and  superposed  on  the  left  one,  which  it  will 


THE    SECOND    METHOD. 


435 


fill;  the  sutural  closure  will  then  be  that  in  which  there  only 
remains  a  small  open  space,  and  this  may  perhaps  be  effaced,  if 
the  sides  h  e  and  e  c  be  subscised. 

The  material  for  closure  can  be  taken  on  either  side  of  the 
defect;  and  thus  the  sutural  scars  and  the  small  opening  left  may 
be  placed  where  they  will  be  but  slightly  conspicuous. 


EiGTJRE  30.     Illustrating  one  method  of  closing  a  triangular  defect. 


-i h 


</ 


Figure  31".     Showing  the  sutural  line  that  remains  after  closure  by  unilateral 
sliding. 

Or  if  the  triangle  stands  as  in  Figure  30,  closure  may  be  done 
by  subscising  the  derm  a  c  d,  and  having  drawn  this  to  the  left, 
suture  it  to  the  side  a  h.  The  remaining  sutural  line  will  be  as  seen 
in  Figure  31.  A  defect  in  this  method  is  that  the  surface  beneath 
the  line  h  d  will,  for  a  time,  be  folded  or  uneven.  This  uneven- 
ness  will,  in  time,  become  less;  yet,  for  a  long  period,  the  tense 


Figure  32.     Showing  Burow's  plan  of  closure. 


43G 


THE    ELEM^:^•T.S    OF    PLASTIC    SURGERY. 


condition  of  the  structures  above  the  line  b  d  will  contrast  with 
the  loose  state  of  the  parts  below  the  line.  To  give  more  uni- 
formity to  tlie  surface,  the  ingenious  conceit  of  Burow  may  be 
utilized;  this  is  done  as  follows:  On  the  extended  line  bcxlet 


FiGiRE  33.  Showing  sutural 
lines  after  closure  by  Burow's 
plan. 


Figure  34.  Showing  sutural 
lines  remaining  after  exsection 
of  two  triangles  done  according 
to  Burow's  plan. 


there  be  excised  from  the  opposite  side  the  triangle  d  ef;  when 
closure  is  made,  the  lines  of  suture  will  have  the  form  here  pre- 


FiGCRE  .3.5.     In  which  two  triangles  are  exsected  to  aid  in  closure  of  ah  c.  as 
done  by  Burow.     Closure  is  seen  in  Figure  34, 

sented.  Or  the  compensating  subsidiary  excision  may  be  done, 
as  presented  in  Figure  35,  in  which  the  base  line  is  extended 
towards  the  left  and  the  right;  and  these  excisions  need  not  be  so 
large  as  the  one  which  it  is  sought  to  close.  The  sutural  union 
will  present  the  appearance  shown  in  Figure  34  A  serious  fault 
in  Burow's  mode  of  closure  is  that  it  nvolves  some  sacrifice  of 
tegumentary  structure;  it  also  multijjlies  scar-lines.  Tegumen- 
tary  sacrifice  cannot  be  made  without  detriment,  derm  once  lost 
is  irrevocably  gone;  nature  has  no  resource  by  which  it  can 
be  reproduced;  and  though  plastic  surgical  art  may  close  a 
breach  in  the  surface  by  the  procedure  which  we  are  considering 


THE    SECOND    METHOD. 


437 


yet  if,  through  destruction  or  sacrifice  of  structure,  much  strain 
be  left  in  tlie  closed  surface,  such  strain  and  tension  will  remain 
as  a  lasting  annoyance  to  the  patient.  It  is  a  fact,  that  should 
not  be  forgotten,  that  in  the  work  of  inclosure  of  the  human 
organism,  the  hand  of  nature  furnished  no  surplus  material  in 
the  inclusive  dermal  and  mucous  teguments.  In  this  furnishing, 
nature  gives  nothing  for  waste. 

Instead  of  closing  the  triangle  by  rectilineal  extension  of  one 
of  its  sides,  the  side  may  be  prolonged  as  a  curved  line,  towards 
the  right  or  left,  and  then  the  line  of  closure  would  be  along  the 
line  a  b  and  b  c  d,  as  will  appear  if  Figure  36  be  studied. 


"Figure  36.     Showing  the  plan  of  closing  a  triangular  defect  by  curvilinear 
extension  of  base  b  c  to  d. 

The  work  of  closing  the  triangle  by  means  of  subsidiary 
incision,  subscision  and  excision  may  be  employed  to  close  the 
lozenge ;  for  as  this  figure  may  be  conceived  as  consisting  of  two 
triangles   resting   on   one   base,   as   shown    in    Figure    37,   the 


Figure  37.     Showing  plan  of  closure  of  the  lozenge-shaped  defect. 


'  ■  1    J  ^    ' H — f 


Figure  38.     Showing  sutural  lines  after  closure  of  the  lozenge-ehaped  defect. 


438 


THE    ELEMENTS    OF    PLASTIC    SURGERY. 


repair  of  such  a  defect  can  be  done  by  closing  each  of  their  tri- 
angles separately.  The  work  is  done  by  extending  a  central 
bisecting  line  towards  the  right  and  the  left;  then  by  subscision 
the  right  side  is  loosened,  and  the  same  is  done  on  the  left  side; 
tlie  right  flap  is  now  to  be  drawn  towards  the  left,  and  the  left 
one  towards  the  riglit.  Thus  closure  will  be  effected,  since  each 
triangle  has  the  same  relation  to  its  fellow  as  does  the  triangle  of 
Burow,  which  is  excised  to  avoid  an  uneven  surface. 


dl^ 


FiGrRE39.  Showing  the 
plan  of  closing  a  parallelo- 
gram by  converting  it  into 
two  triangles. 


Figure  40.  Exhibiting 
line  of  suture  after  closure 
of  a  quadrangular  defect 
that  has  been  divided  into 
two  triangles. 


A  quadrangular  defect  can  be  closed  by  employing  the  prin- 
ciples here  given;  viz.,  by  the  closure  of  the  triangles  into  which 
a  rectangle  or  parallelogram  can  be  divided.  For  example,  let  the 
figure  b  ce  dhe  converted  into  two  triangles  as  shown  in  Figure 
39.  Next  extend  the  side  d  b  to  a,  and  the  side  c  e  to/,  and  then 
dissect  up  the  flaps  ab  c  and  d  e  f.  These  flaps  can  be  drawn 
towards  each  other,  when  the  sutural  line  will  be  as  shown  in 
Figure  40.     The  quadrangular  defect  may  be  closed  in  another 


a 


Figure  41.     Showing  a   plan  of 
closing  a  quadrangular  defect. 


Figure  42.  Exhibiting  the  sutural 
lines  remaining  after  closure  of  the 
quadrangular  defect,  as  indicated  in 
Figure  4i. 


THE   SECOND    METHOD. 


439 


I  \   t 


1-1- 


4— t^ 


-M- 


Figure  43.      Presenting    another 
plan  of  closing  a  quadrangular  defect. 


riGURK44.  Showing  sutural  line 
which  remains  after  closure  of  a  quad- 
rangular space,  as  indicated  in  Figure 
43. 


way,  as  exhibited  in  Figure  41,  in  which  the  replacing  material  is 
incised  in  the  form  of  angular  flaps;  in  this  way  the  open  paral- 
lelogram ah  G  e  can  be  closed  by  sliding  upwards  the  right  and 
left  flaps;  meanwhile  the  adherent  angular  portion  d  f  will  aid 
in  supporting  and  retaining  in  site  the  uplifted  lateral  flaps. 
This  defect  might  also  have  been  closed  by  incisions  made  as 
shown  in  Figure  43,  in  which  median  flaps  are  uplifted  at  A  and 
B,  and  the  lateral  ones,  C  and  D,  are  dissected  up:  thus  a  defect 
of  moderate  dimensions  may  be  closed;  and  the  sutural  lines  will 
appear  as  shown  in   Figure  44.     The  mechanical  advantages 


i ^ 


Figure  45.  Exhihitingclosureofa 
rectangular  defect  by  sliding  an  adja- 
cent flap  into  it.  An  adjuvant  cres- 
centic  incision  is  shown  beneath. 


Figure  46.  In  which  is  shown  lat- 
eral closure  of  a  rectangle  after  re- 
placement by  a  lateral  flap. 


440 


THE  ELEMENTS  OF  PLASTIC  SURGERY. 


gained  by  this  species  of  closure  are  that  the  median  and  lateral 
flaps  when  fixed  in  position,  mutually  hold  each  other  in  place. 
Another  plan  of  closing  a  rectangular  defect  is  shown  in  Figure 
45,  in  which  a  lateral  flap  being  uplifted  and  thrust  into  the 
space  and  sutured  there,  the  appearance  will  be  as  shown  in 
Figure  40,  If  in  the  construction  of  the  flap  one  makes  a  semi- 
circular incision  beyond  its  pedicle,  as  shown  in  the  figure,  the 
work  of  closure  will  be  facilitated. 

In  the  third  method,  in  which  a  pedicled  flap  is  traced  out  on 
the  contiguous  surface,  and  then  incised,  uplifted,  and  revolved 
into  its  destined  site,  closure  of  a  shapeless  or  irregular  defect 
may  be  done,  provided  the  closing  material  has  corresponding 
outlines;  still,  even  here,  the  oj^erator  will  solve  the  problem  of 
closure  more  readily  if  he  can  convert  his  defect  into  a  circular, 
oval,  triangular,  or  quadrilateral  figure.  In  the  preparation  of 
the  repairing  fla^j,  since  the  pedicle  is  to  be  subjected  to  torsion, 
provision  against  tension  should  be  made  by  having  the  flap  long- 
enough;  for  traction  and  torsion,  and  the  tension  consequent 
on  these,  can  arrest  the  vitality  of  the  shifted  structure.  Yet 
this  is  readily  avoided  if  the  flap  have  ample  proportions. 

As  has  been  mentioned  in  the  third  method  of  the  plastic  pro- 
cedure, the  replacing  flap  must  be  turned  through  the  entirety  or  the 
whole  of  a  semicircle;  and  the  surgeon  should  endeavor  to  ren- 
der this  arc  as  short  as  possible.  The  pedicle  must  be  broad 
enough  to  insure  a  sufficient  supply  of  blood  to  the  flap  ;  and  to 
guarantee  this,  the  foot-stalk,  when  median  frontal  material  is 
used,  should  have  a  breadth  of  not  less  than  two-thirds  of  an 
inch.  The  component  tissue  of  the  flap  must  be  sound  and  not 
deteriorated  hy  cicatrix  or  other  defect. 

A  few  examples  of  the  employment  pf  this  mode  will  now  be 
presented  with  diagrammatic  illustration. 


Figure  47.    Showing  a  method 
of  closing  a  circular  defect. 


FiGCEE  48.  Exliibiti  ng  the 
appearance  after  closure  of  a 
circular  defect  by  the  use  of 
subjacent  flaps. 


THE    THIRD    METHOD. 


441 


One  plan  of  closing  a  circular  defect  by  the  use  and  circum- 
duction of  adjacent  flaps  is  presented  in  Figure  47,  and  the 
appearance  after  closure  is  seen  in  Figure  48.  The  unclosed 
space  d  might  be  repaired  by  Thiersch's  method  of  epidermal 
grafts. 

The  circular  defect  can  be  closed  by  another  method,  as  shown 
in  Figure  49.     Let  the  flaps  a  h  and  c  d  be  incised,  loosened  and 


:    A    ;    ? 

L  -  -' 
FiGPRE   49.      Showing 
closure  of  the  circular  de- 
fect. 


FiGUEE  50.     Showing  sutural  lines 
after  closure  of  the  circle. 


turned,  one  upwards  and  one  downwards,  so  as  to  occupy  the 
circle;  the  line  of  suture  is  shown  in  Figure  50,  and  if  the  work 
be  examined,  it  will  be  seen  that  the  sutured  flaps  mutually  hold 
and  maintain  each  otlier  in  place.  After  completion  there  will 
remain  an  uncovered  space  at  what  a  geographer  would  desig- 
nate the  upper  and  lower  poles  of  the  circle. 


Figure  51.     Showing  method  of  closing  a  semicircular  defect. 

A  semicircular  space  may  be  closed  by  uplifting  the  flaps  a 
and  b,  in  Figure  51,  and  turning  them  into  and  attaching  them  to 
the  margin  of  the  defect  S  C,  The  circle  might  have  its  com- 
ponent semicircles  closed  in  a  similar  way.  The  ov^l  and  ellip- 
tical defect  can  be  closed  by  the  modes  just  presented  for  the 
closure  of  the  circle  and  semicircle. 

The  third  method  of  plastic  repair,  in  which  the  work  is  done 
29 


442 


THE  ELEMENTS  OF  PLASTIC  SURGERY. 


by  the  circumduction  of  a  pedicled  flap  of  proper  form  to  close 
the  defect,  is  applicable  to  the  repair  of  the  triangular  and  quad- 
rangular space;  for  example,  the  triangle  A,  seen  in  Figure  52, 


Figure  52.    Showing  closure 
of  triangle  A  by  shifted  flap. 


Figure  53.    Showing 
closure  of  triangle  B. 


may  be  closed  by  a  plan  in  which  the  flap  c  d  is  turned  into  the 
space  a  b  c.  Or  the  flap  a  may  be  shifted  into  the  space  B,  shown 
in  Figure  53;  or  tliis  may  be  done  by  flaps  taken  from  the  right 
and  left  sides,  as  in  the  triangle  C,  Figure  54,  which  may  be  closed 
by  the  flaps  a  and  b. 


Figure  54.     Showing  closure  of  triangle  C. 

The  quadrangle  A  may  be  closed  by  the  quadrangular  flap  ch  d, 
which,  being  prepared,  is  to  be  revolved  into  the  space  A,  as  seen 
in  Figure  55.  In  thus  closing,  the  angular  portion  of  remaining 
tissue  represented  by  c  gives  a  support  to  the  shifted  flap  b,  and 
the  surface  will  be  closed  except  a  small  space  lying  at  the  right. 


c/ 


/ 


Figure  55.     Showing  a  plan  of  closing  a  quadrangle  A  by  the  shifted  flap  chd' 


THE    THIRD    METHOD. 


443 


/     X  -J 

FiGHRE   56.     Showing   closure  of  Figure  57.    Representing  the  su- 

an  oval  space.  tural  line  after  closure  of  an  oval  de- 

fect. 


P 


An  oval  defect,  as  shown  in  Figure  56,  may  be  covered  by  a 
flap,  which,  being  dissected  up,  is  to  be  uplifted  until  the  side  d  a 
is  brought  in  contact  with  the  side  d  e,  when  the  sutural  closure 
will  be  as  shown  in  Figure  57,  with  a  space  remaining  open  at 
X.    A  semicircular  space,  shown  in  Figure  B,  may  be  closed  by 


\>  \ 


Figure  58.     Exhibiting  a  plan  of  closing  a  semicircular  space  B  by  lateral 
flaps. 

incising  two  flaps,  a  and  b,  at  the  sides,  and  turning  these  into 
the  breach,  when  the  closure  will  be  as  shown  in   Figure  59. 


/ 


Figure  59.     Showing  sutural  line 
after  closure  of  a  semicircular  defect. 


Figure  60.  Showing  another  plan 
of  closing  a  semicircular  defect  by 
means  of  a  single  flap. 


The  semicircular  space  C,  shown  in  Figure  60,  can  be  (jlosed  by 
a  flap  of  similar  shape,  d,  taken  from  the  overlying  surface- 
Instead  of  one  large  replacing  flap,  two  smaller  ones  might  be. 
formed  on  each  side  above,  as  shown  in  Figure  61. 


444  THE  ELEMENTS  OF  PLASTIC  SUKGEKY. 


FiGCKE  61.     Illustrating  closure  of  a  semicircular  space  A  by  means  of  two 
flaps,  a  and  b. 

Having  described  tlie  tliree  methods  of  plastic  repair  by  whicli 
a  breach  of  surface  may  be  closed,  and,  in  a  measure,  concealed, 
if  they  be  compared  with  each  other,  it  will  be  found  that  the 
first  is  applicable  where  the  surface  to  be  closed  is  small  in  extent; 
the  second  is  suited  to  cases  in  which  the  breach  is  larger,  and 
the  third  method  may  be  resorted  to  in  cases  in  which  the  open 
breach  is  irregular  or  regular  in  outline,  and  the  replacing  flap 
can  be  selected  and  taken  from  the  surface  near  to,  but  not  con- 
tinuous with,  the  border  of  the  breach.  The  second  and  third 
methods  add  wounds  to  the  one  which  it  is  sought  to  close.  Yet 
tlie  additional  wound,  in  the  case  of  a  flap  that  is  revolved,  can, 
sometimes,  be  made  where  it  will  remain  concealed  or  but  slightlv 
conspicuous.  And  as  the  flap  is  uplifted  at  a  slight  distance  from 
the  open  defect,  the  secondary  wound  can  often  be  clo.sed;  and 
any  tension  caused  bj'this  adjacent  closure  will  not  influence  the 
wound  into  which  the  flap  is  turned.  The  transplanted  flap 
should  consist  of  sound  derm  which  can  readily  be  shifted. 
^Muscular  tissue  is  not  adapted  to  such  work,  for  it  changes  to 
fibrous  tissue,  which,  contracting  or  shriveling,  deforms.  A  flap 
clad  with  a  thick  mass  of  fatty  tissue  is  unsuited  as  material  for 
repair;  but  in  case  none  other  is  available,  it  may  be  used;  and 
then  the  entire  thickness  of  the  fatty  couch,  with  the  subjacent 
fascia,  should  be  used.  If  tlie  derm  be  separated  from'such  adi- 
pose couch,  it  is  apt  to  die;  also,  if  a  thin  structure  of  adeps  be 
retained  with  the  derm,  it  ill  performs  the  function  of  material 
for  re  lacement,  as  the  writer  has  often  verified.  The  minute 
lobules  of  adeps  constituting  the  fatty  couch  are  so  disturbed  in 
their  vitality  when  they  are  divided  or  split,  that  they  contract 
but  imperfect  adiiesions  with  otlier  tissues.  Dissolving  adipose 
material  is  a  medium  more  suited  for  the  separation  than  for  the 
union  of  wounded  parts.  The  flap  which  has  the  best  qualities 
for  plastic  replacement  is  one  of  derm  with  a  thin  stratum  of 
fascia;  and  this  will  cohere  to  any  structural  compound  of  the 


OTHER    METHODS.  445 

body;  for  example,  it  will  unite  with  periosteum,  denuded  bone, 
or  denuded  cartilage,  tendon,  muscle,  nerve  and  adipose  structure. 
Union  to  adipose  structure  is  promoted,  if  the  latter  has  a  fascial 
covering. 

The  transposed  flap  is  influenced  by  the  structure  which 
supports  it ;  if  this  be  firm  and  immovable,  for  example,  a  flat 
bone,  the  flap  will  contract  adhesions  to  it,  and  undergo  but 
slight  subsequent  change;  yet  planted  on  an  unstable  muscle,  the 
flap  will  undergo  displacement  and  deformity. 

The  work  of  final  closure  must  be  preceded  ])y  complete 
staunching  of  all  bleeding,  especially  when  the  work  is  done  by 
the  flap  method.  No  vessel  must  be  left  bleeding  beneath  the 
newly  planted  tissue.  Bleeding  from  the  surface  may  be  arrested 
by  irrigating  with  ice  water;  or,  should  a  vessel  of  some  calibre 
continue  to  bleed,  this  may  be  closed  by  torsion.  Ligatures 
should  not  be  used.  Closure  should  be  done  by  knotted  suture 
with  fine  aseptic  silken  thread.  Fine  wire  may  likewise  be  used; 
this  may  be  made  of  copper  which  has  been  gilded  or  plated;  and 
this  may  be  either  tied  or  twisted;  and  in  whatever  way  closure 
is  effected,  care  must  be  taken  that  the  cord  or  wire  is  not  toO' 
tightly  drawn,  for  too  tight  closure  pinches  the  patient  and  often 
kills  tbe  included  structure. 

In  case  of  lateral  sliding,  in  which  the  parts  are  tightly 
stretched  in  the  approximative  closure,  the  strain  should  be 
relieved  by  tension -relieving  sutures.  Such  sutures  should  be  of 
wire,  and  so  introduced  as  to  include  from  a  half  inch  to  one 
inch  of  the  structures  which  are  to  be  united.  These  strain- 
opposing' sutures  need  be  but  few  in  number;  two  or  three  will 
suffice,  and  these  should  remain  in  place  for  not  less  than  one 
week;  and  even  a  longer  time  is  sometimes  necessary;  for  if  these 
supporting  sutures  be  removed  too  early,  the  intermediate  united 
edges  may  tear  asunder. 

Besides  the  strain-oi^posing  suture  and  that  of  simple  closure, 
as  additional  aids,  one  may  resort,  sometimes,  to  those  species  of 
sutures  familiarly  called  the  mattrass,  quill  and  pin,  or  twisted 
suture.  The  mattrass  suture  can  be  used  to  bind  down  and  fix 
in  position  a  section  of  a  flap  which  tends  to  rise  from  the  sub- 
jacent surface.  This  suture,  which  should  be  of  silk,  is  inserted 
by  means  of  a  needle  which  is  strongly  curved;  the  thread 
includes  a  small  portion  of  the  interior  of  the  flap  and  the  sup- 
porting substratum.  It  is  well  to  use  this  device  of  fixation 
wherever  the  implanted  flap  is  broad.     The  quill  or  brace  suture 


446  THE    ELEMENTS    OF    I'LASTIC    SURGERY. 

is  advantageously  used  where  the  defect  is  an  oblong  breach, 
having  the  long  sides  somewhat  parallel  with  each  other.  The 
brace  or  flattened  rod  of  suitable  length  is  to  be  passed  through 
the  looped  ends  of  doubled  sutures  on  one  side,  and  a  similar  one 
laid  on  the  opposite  side  of  the  defect  is  to  be  introduced  between 
the  other  ends  of  the  sutures,  and  the  free  ends  are  then  to  be 
drawn  upon  so  as  to  close  tlie  breach;  and  when  this  is  effected, 
the  free  ends  are  to  be  tightly  tied  on  the  second  brace. 

In  this  way,  in  a  piece  of  plastic  work  done  on  the  cheek,  the 
writer  has  succeeded  in  closing  a  very  wide  Ijreach  of  surface. 
Such  suture  must  enter  and  emerge  at  a  distance  of  not  less  than 
a  half  inch  from  the  borders  of  the  defect.  And  should  the  su- 
tures cut  the  included  tissue,  the  threads  may  again  be  tied  more 
tightly.  The  Cjuill  or  brace  suture  is  but  a  form  of  a  tension- 
relieving  stitch.  The  pin  or  twisted  suture  may  be  used  to  sus- 
tain and  immobilize  approximated  edges,  or  a  sliifted  flap.  An 
objection  to  it  is  that,  in  the  later  act  of  removing  it,  the  healing 
parts  may  be  disturbed  or,  possibly,  torn  asunder.  The  applica- 
tion of  these  more  unusual  forms  of  suture  should  be  as  limited 
as  possible;  they  are  complicated  and  demand  experience  for 
their  successful  use.  In  nearly  all  cases,  the  simple  knotted 
suture  will  suffice.  Surgical  vork  approaches  nearest  the  line  of 
perfection  when  its  component  technical  elements  are  of  the  greatest 
simplicity. 

Wlien  plastic  operations  are  done  in  the  vicinity  of  natural 
openings  of  the  body,  of  which  the  edges  and  lining  are  lined 
with  mucous  or  semi-mucous  membrane,  it  is  necessary  to  restore 
this  mucous  investment  in  order  to  maintain  the  calibre  of  the 
opening  and  to  prevent  adherence  of  denuded  surfaces.  Such 
natural  openings  are  the  lips  and  oral  cavities,  the  eyelids,  the 
nostrils,  the  lining  of  the  auditory  meatus,  the  urinary  meatus, 
vagina  and  its  outlet,  and  the  anal  opening  of  the  rectum.  To 
counteract  stricture,  atresia  and  synechia,  tlie  denuded  surface 
should  have  an  investment  of  mucous  membrane  or  derm.  If 
the  mucous  membrane  be  used  for  this  purpose,  it  must  not  be 
too  thin,  but  the  sub-mucous  tissue  should  be  uplifted  with  the 
membrane  so  as  to  insure  the  vitality  of  the  transported  structure. 
Wlien  the  mucous  membrane  is  closely  adherent  to  the  parts 
which  it  lines,  it  cannot  be  used  unless  a  stratum  of  subjacent 
structure  be  uplifted  with  it;  but  in  tlie  cartilaginous  portion  of 
the  nose,  the  close  adhesion  of  both  derm  and  mucous  membrane 
to  the  cartilage  renders  it  difhcult  or  impossible  to  utilize  them. 


CARE    OF    THE    WOUXDS.  447 

The  plastic  work  being  com^^leted,  an  important  duty  yet 
remains  in  which  both  patient  and  surgeon  have  a  share;  tliis 
consists  in  protective  care  of  tlie  wounded  parts;  rest,  most  careful 
rest,  should  be  given  to  the  part,  for  the  hand  of  nature  in  adjust- 
ing the  delicate  acts  and  processes  of  repair,  tolerates  no  jostling 
or  disturbing  movement.  Another  adjuvant,  having  great  bear- 
ing on  this  work,  is  that  the  patient  should  be  in  good  health 
when  the  work  is  done;  for  example,  if  in  the  face  or  mouth,  no 
plastic  operation  should  be  performed  when  the  patient  has  a 
cough;  from  this  cause  failure  has  attended  work  done  by  the 
writer.  The  supervention  of  a  diphtheritic  attack  rendered  plastic 
work  null  and  void;  and  it  would  be  difficult  to  2:>rovide  against 
such  misadventure. 

Where  the  work  has  consisted  of  the  simple  juxtaposition  of 
opposite  margins,  after  sutural  closure,  the  remaining  seam 
should  be  dressed  by  coating  it  with  compound  tincture  of 
benzoin;  and  over  this  should  be  placed  a  layer  of  lint  moistened 
with  diluted  alcohol.  And,  as  further  protection  of  the  part, 
this  lint  should  be  retained  in  place  by  broad  strips  of  rubber 
adhesive  plaster.  As  soon  as  the  wouiid  has  united,  the  sutures 
must  be  removed;  if  the  suture  remain  too  long  in  place,  it  will 
leave  a  scar,  viz.,  a  white  point,  which  will  remain  permanent; 
hence  where  the  suture  merely  maintains  connection  between 
opposed  borders,  and  the  parts  are  not  stretched,  the  suture  may 
be  safely  removed  at  the  end  of  two  days.  An  earlier  removal, 
advised  by  some  surgeons,  is  not  in  accord  with  the  writer's 
experience.  Should  it  be  apparent  that  the  stitches  are  irritating 
the  structures,  and  that  suppuration  impends,  then  there  should 
be  no  delay  in  removal.  The  tendency  of  the  suture  to  irritate 
will  be  lessened  if  the  thread  or  wire  used  be  duly  proportioned 
to  the  needle  which  carries  it ;  the  thread  or  wire  must  not  be  too 
large;  for  if  this  be  so,  and  the  suture  exceeds  the  orifice  through 
which  it  passes,  then  it  will  press  on  and  destroy  the  tissue 
adjacent  to  it.  And,  again,  the  thread  or  wire  must  not  be  too 
small  for  the  orifice,  the  rule  being  that  the  carrying  needle 
should  be  slightly  larger  tlian  the  thread  which  it  bears. 

As  a  general  rule  for  this  work,  a  few  sutures  may  be  removed 
near  the  end  of  the  second  day;  on  the  third  day,  others  can  be 
extracted,  and,  on  the  fourth,  all  may  be  removed  except  those 
which  were  introduced  to  oppose  and  relieve  strain.  The  cutting 
and  extraction  of  the  sutures  must  be  done  with  care;  the  cutting 
must  be  done  on  one  side,  and  as  close  to  the  surface  as  possible, 


448  THE    ELEMENTS    OF    PLASTIC    SURGERY. 

after  the  suture  has  been  slightly  uplifted,  so  that  the  end  to  be 
pulled  througli  shall  have  no  dried  excreta  adherent  to  it,  which, 
catching  in  the  sutnral  canal,  would  cause  tugging  on  the  parts. 

Should  the  united  edges  be  torn  slightly  apart  in  the  removal 
of  the  sutures,  as  sometimes  happens,  then  tlie  blood  which 
exudes  should  be  allowed  to  dry,  and  strips  of  Emplastrum 
Ichthyocollse  should  be  placed  across  the  breach,  so  as  to  keep 
the  parts  at  rest,  and  insure  their  reunion. 

After  healing  has  occurred,  there  often  remain  some  minor 
defects  in  the  parts  operated  on  which  require  attention.  In 
turning  the  pedicled  flap  to  its  destined  site,  the  pedicle  is  often 
left  in  an  irregular,  twisted  shape,  which  disfigures  the  surface. 
After  healing  has  advanced  so  far  that  the  vitality  of  the  flap  is 
guaranteed,  even  though  the  pedicle  were  severed,  then  any 
irregular  eminence  or  contorted  edge  can  be  removed,  and  the 
surface  rendered  even.  In  this  leveling  work,  the  outer  face  of 
the  derm  should  be  saved  if  possible  and  employed  to  cover  any 
wound  which  may  be  made.  Again,  in  the  union  of  margins  by 
sliding,  if  one  side  exceed  the  other  in  length,  there  will  remain 
a  fold  or  two  on  the  larger  side.  Such  folds  in  time  will  gradu- 
ally subside;  they  may  also  be  lessened  or  prevented  by  one  or 
more  cuneiform  excisions  from  the  larger  side.  Such  excised 
gap  is  to  be  closed  by  suture.  Care  must  be  used  not  to  excise 
too  much.  In  fact,  though  such  excision  of  surplus  material  is 
generally  practised,  it  is  probable  tiiat,  if  it  were  not  done, 
in  time  the  unevenness  would  vanish  through  a  process  of 
involution,  in  which  the  excess  would  become  merged  in  the 
common  surface,  and  aid  in  relaxing  the  tension.  In  studies  on 
the  best  means  of  disposing  of  the  sur])lus  integument,  which 
remains  after  the  removal  of  lipomata  or  other  benign  neoplasm, 
Sir  William  Fergusson  strongly  urged  to  save  the  exuberant 
derm  which  remained  after  the  removal,  on  the  ground  that  it 
will  afterwards  become  gradually  incorporated  in  the  surround- 
ing integument.  In  the  history  of  pla,stic  surgery  one  fact  has 
repeatedly  been  verified,  that  there  is  an  atrophic  tendency  in  the 
structures  which  have  been  operated  on;  in  time  they  invariably 
become  lessened  in  volume;  this  has  repeatedly  been  observed  in 
the  new-formed  nose  of  inordinate  proportions.  In  all  such 
cases  the  new-formed  channels  which  are  opened  for  the  vascular 
supply  of  the  part  are  usually  inadequate  for  tiie  continuance  of 
normal  nutrition.  Hence,  in  nearly  all  cases,  the  rule  of  guid- 
ance should   be   that   the   retrenchment   of  seemingly   surplus 


Thiersch's  method  of  transplantation.  449 

structures,  instead  of  being  done  by  the  scalpel,  should  be 
intrusted  to  the  cautious  care  of  nature,  whose  unostentatious 
effort,  if  fair  justice  were  done,  would  often  be  crowned  with  the 
adornment  of  laurels  which  are  awarded- to  the  surgeon's  work. 

As  concluding  lines  of  this  chapter  on  plastic  surgery,  it 
should  be  stated  that,  though  much  is  essayed,  and  much  is  done 
in  this  attractive  field  of  art,  yet  the  modest  confession  is  due  that 
when  a  calm  survey  is  made  of  the  best  results  which  can  be 
obtained,  and  the  latter  be  compared  with  the  unmarred  human 
form,  the  best  plastic  procedure  can  seldom  furnish  more  than  a 
tolerable  counterfeit  of  the  excellent  original. 

Thiersch's  Method  of  Cutaneous  Trarisplantation. — Besides  the 
modes  of  repairing  breaches  in  dermal  continuity  which  have 
been  described,  the  work  may  be  done  by  a  procedure  which  is 
designated  grafting,  or  transplantation.  Experience  acquired  in  the 
physiological  and  vivisective  laboratory  demonstrated  the  possi- 
bility of  removing  small  portions  of  the  animal  body  and  trans- 
planting the  detached  tissue  elsewhere  in  the  body. 

The  utilization  of  the  animal  graft  was  early  heralded  by 
Paul  Bert,  who  announced  that  one  day  "those  who  are  occupied 
with  morbid  physiology  would  derive  the  most  useful  results 
from  it."  Though  grafting  was  essayed  with  many  tissues  of  the 
body,  it  was  chiefly  in  the  repair  of  defects  of  the  dermal 
structures  that  the  first  experiments  were  made. 

To  J.  L.  Reverdin,  in  1869  and  1870,  is  due  the  honor  of 
using  small  epidermal  grafts  for  the  closure  of  a  breach,  especially 
that  due  to  an  ulcer  in  the  surface  of  the  body.  In  the  employ- 
ment of  his  procedure,  Reverdin  had  numerous  collaborators 
among  the  surgeons  of  France,  Germany  and  England;  so  that 
but  a  brief  time  elapsed  before  many  reports  were  published 
highly  favorable  to  the  process,  popularly  known  as  skin-grafting. 

In  the  method  of  Reverdin,  the  operator  seizes  with  fine- 
toothed  forceps  the  skin  from  which  the  graft  is  to  be  taken, 
uplifts  the  surface,  and  with  a  pair  of  small  curved  scissors  he 
excises  the  uplifted  point;  the  latter  is  then  placed  on  the  part  to 
be  repaired,  and  pressed  somewhat  inwards,  and  allowed  to 
remain  in  its  new  site.  From  tlie  islet  of  engrafted  tissue  lines 
of  new  material  shoot  out  horizontally,  and  seem  to  be  attracted 
by  similar  lines  from  neighboring  grafts,  the  result  being  a  great 
increase  in  the  activity  of  cicatricial  closure  of  the  raw  surface. 

The  method  of  Reverdin  underwent  modifications  in  the 
hands  of  other  surgeons;  in  place  of  the  thin  cuticular  section, 


450  THE    ELEMENTS    OF    PLASTIC    SURGERY. 

much  thicker  ones  were  used  for  transplantation,  until  linally 
those  of  the  entire  thickness  of  the  derm  were  emj)loyed. 

But  by  far  the  most  important  modification  was  that  intro- 
duced by  Professor  Thiersch,  of  Leipsig,  who  discovered  that 
epidermal  grafts  of  almost  indefinite  length  may  be  made  to  grow 
on  a  raw  surface.  This  discovery  was  published  in  3887,  tliough 
Thierscli,  it  is  said,  had  previously  been  studying  the  matter  for 
some  years;  and  his  discovery  was  made  during  researches  under- 
taken to  solve  the  problem  of  the  microscopic  phenomena  which 
are  present  in  the  healing  of  wounds,  and  especially  the  disposi- 
tion^ of  the  vessels  in  an  ulcerated  surface. 

In  a  microscopic  examination  of  the  ground  of  a  chronic 
ulcer,  Thiersch  found  that  the  capillaries  in  the  upper  and  deeper 
portions  have  a  different  arrangement,  viz.,  those  in  the  upper 
stratum  stand  vertical,  while  the  deeper  capillaries  are  disposed 
horizontally.  The  tissue  supplied  with  vertical  capillaries  has 
nearly  lost  the  quality  of  further  development;  and  before  such  a 
surface  is  fitted  for  cicatricial  closure,  Thiersch  found  that  it 
required  a  preliminary  preparation. 

The  Thiersch  procedure,  though  first  only  used  for  the  closure 
of  ulcerated  surfaces,  has  now  been  extended  to  fresh  wounds 
involving  any  part  of  the  surface  of  the  body;  and  it  matters  but 
little  whether  the  wound  be  dermal,  muscular,  adipose  or  osse- 
ous, the  process  has  proved  successful  in  all  these  sites. 

Besides  the  repair  of  fresh  wounds  and  ulcers- recent  or  chronic, 
this  method  has  been  used  and  found  a  valuable  aid  in  the  treat- 
ment of  burns,  contracted  scars,  syndactylia  and  all  abnormally 
coherent  surfaces. 

Though  Thiersch  was  one  of  the  first  Germans  who  embraced 
the  antiseptic  plan  of  treating  wounds,  yet  in  the  work  of  skin- 
grafting  he  did  nc^t  apply  antiseptic  agents  to  either  the  wound 
to  be  closed  or  to  the  material  of  closure.  Others,  however,  ni 
the  work  do  use  antiseptics.  Jungengel  and  Iliipscher,  who 
have  written  on  the  procedure,  have  applied  to  the  wound,  ulcer, 
grafts  and  instruments,  a  two  per  cent  solution  of  carbolic  acid,  or 
a  ToVo  solution  of  sublimate.  Thiersch  used  only  a  solution  of 
chloride  of  sodium,  known  as  the  physiological  solution,  which 
contains  six  grains  of  the  salt  in  one  thousand  grains  of  water. 

The  material  for  grafting  is  commonly  taken  from  the  subject 
on  whom  the  transplantation  is  to  be  done,  yet  it  has  been  derived 
from  another  person,  also  from  the  integument  of  amputated 
limbs.     For  several  reasons  it  is  better  to  be  taken  from  the  per- 


Thiersch's  method  of  transplantation  451 

son  on  whom  it  is  to  be  used ;  and  the  sites  from  which  it  is  most 
easily  excised  are  the  front  surface  of  the  thigh  and  the  extensor 
side  of  the  upper  arm. 

The  surface  furnishing  the  sections  for  grafting  should  be 
carefully  cleansed,  and  this  is  done  by  first  washing  it  with  soap 
and  water,  then  with  a  two  per  cent  of  carbolized  water,  and  finish- 
ing with  a  free  use  of  the  solution  of  chloride  of  sodium  above 
mentioned. 

The  surface  to  be  closed  requires  some  preliminary  treatment. 
In  case  of  a  breach  the  site  of  ulceration,  the  superficial  struc- 
ture should  be  removed;  and  Thiersch  and  others  do  this  with  a 
sharp  curette,  but  the  author  prefers  to  do  this  work  by  incision 
with  a  long-bladed  scalpel.  The  scalpel  prepares  a  much 
smoother  ground  than  does  the  curette,  however  sharp  this 
instrument  may  be.  If  the  ulcer  have  borders  of  irregular  out- 
line, these  should  be  converted  by  incision  into  regular  figure. 
Closure  is  easy  in  a  surface  of  oval  form. 

Besides  the  ulcer,  fresh  wounds,  in  which  the  skin  has  been 
lost,  are  suited  for  closure  by  Thiersch's  method.  Such  breach 
must  have  a  smooth  ground. 

If  the  surface  to  be  closed  is  bleeding,  care  must  be  taken  that 
the  blood  has  been  staunched,  and  that  all  clots  have  been 
removed;  and  for  this  purpose  irrigation  with  the  solution  of 
salt  must  be  carefully  done. 

The  thickness  of  the  grafts  is  the  subject  of  difi'erence  among 
operators.  Thiersch  advises  that  the  graft  include  the  epiderm, 
papillary  layer  and  a  small  section  of  the  corium.  Graser,  Ever 
busch  and  Hiibscher  recommend  the  use  of  thinner  sections,  viz., 
such  as  contain  the  cuticle  and  the  summits  of  the  papillae.  The 
thickness  of  the  graft  will  vary  according  as  it  is  broad  or  nar- 
row; when  broad,  the  central  portion  of  the  graft  must  be  thick, 
and  contain  at  least  the  entire  papillary  layer  of  the  derm. 

The  length  of  the  sections  for  grafting  must  necessarily  vary 
according  to  the  surface  to  be  closed.  Elongated  breaches  have 
been  closed  by  sections  which  were  over  a  foot  long.  The  longer 
and  broader  the  grafts  are,  the  more  expeditiously  the  work  can 
be  completed. 

For  excising  the  grafts,  a  razor,  or  similar  instrument,  may  be 
used;  the  one  most  appropriate  is  a  razor-like  blade,  of  which 
one  side  is  plane  and  the  other  incurved.  The  microscopic  stu- 
dent of  former  years,  who  used  a  razor  and  not  a  microtome  to 
cut  his  sections,  has  acquired  that  use  of  the  hand  which  makes 


452  THE    ELEMENTS    OF    PLASTIC    SURGERY. 

him  expert  in  excising  the  skin  graft.  The  instrument,  grasped 
firmly,  is  to  be  brought  in  contact  with  the  surface,  and,  being 
held  at  a  very  acute  angle  to  the  latter,  the  work  of  cutting  is 
done  by  a  rapid  sawing  movement. 

The  surface  whence  the  graft  is  taken  must  be  rendered  tense; 
and  if  this  l^e  the  upper  arm  or  thigh,  tension  of  tlie  skin  is  to 
be  made  by  an  assistant  grasping  laterally  the  limb  with  both 
hands  and  stretching  the  intervening  space;  and  the  operator 
can  aid  also,  if  he  slides  the  'skin  upwards  or  downwards  from 
the  cutting  instrument. 

The  excised  grafts  may  be  carried  immediately  to  their 
destined  site;  but  if  it  is  not  convenient  to  complete  the  work  at 
once,  the  sections  may  be  preserved  for  some  hours  in  the  saline 
solution.  If  they  are  used  immediately,  they  may  be  transferred 
from  the  cutting  blade  by  letting  a  small  current  of  the  saline 
fluid  trickle  on  the  section,  and  float  it  from  the  end  of  theinstru- 
ment  to  the  surface  to  be  closed.  This  transference  can  be  aided 
by  using  a  probe.  The  graft  tends  to  fold  towards  its  incised 
side,  and,  in  placing  it  in  position,  this  curling  must  be  corrected 
with  the  probe  and  index  finger,  so  that  the  raw  face  of  the  graft 
will  lie  directly  on  the  surface  that  is  to  be  closed. 

Where  more  than  one  graft  is  to  be  used,  the  sections  are  to 
be  so  placed  that  the  margin  of  the  second  graft  will  slightly  lie 
on  the  edge  of  the  first  one, — the  series  lying  like  tiles  on  a  roof. 
Bv  thus  proceeding,  no  interstices  will  remain,  and  the  surplus 
margins  will  soon  detach  themselves. 

The  excision  of  the  grafts  may  be  done  under  anaesthesia, 
provided  the  breach  to  be  closed  has  arisen  from  operative  work 
in  which  the  patient  was  ana'sthetized.  Yet  it  is  sometimes  done 
without  anaesthesia,  the  patient  then  reporting  that  the  sensa- 
tion was  similar  to  that  of  shaving  with  a  dull  razor. 

The  surface  whence  the  grafts  are  cut  soon  heals  under  a.sep- 
tic  dressing;  it  remains  discolored  for  a  time,  and  in  rare  cases  it 
becomes  the  site  of  a  keloid  growth. 

After  the  grafts  are  in  position,  they  often  become  uplifted  by 
subjacent  bleeding;  and  if  this  be  considerable,  the  work  will  fail 
unless  the  blood  be  removed  and  the  grafts  be  properly  placed 
again.  If  the  amount  of  blood  beneath  the  grafts  be  slight,  the 
grafts  may  become  ecchymosed,  yet  still  retain  their  vitality, 
and  closure  be  accomplished. 

As  to  the  dressing  of  the  transplanted  surface,  different  modes 
exist.     To  protect  the  grafts  and  retain  them  in  place,  strips  of 


Thiersch's  method  of  transplaxtatiox.  453 

gutta  percha  tissue  paper  may  be  used.  Such  strips  may  also  be 
employed  to  transfer  the  grafts  from  a  solution  in  which  they 
iiave  been  temporarily  retained  to  the  breach  to  be  closed;  and 
when  the  grafts  are  thus  placed,  the  carrying  tissue  paper  may 
be  used  as  the  protective  covering;  and  as  final  dressing,  dry  or 
moist  aseptic  gauze  may  be  placed  over  the  closed  wound. 

If  it  becomes  necessary  to  frequently  change  the  dressing, 
gauze  smeared  with  berated  vaseline  (xfo)  is  recommended  for 
the  purpose.  Yet  usually  dry  dressing  is  employed;  and  then 
the  whole  may  consist  of  a  layer  of  gutta  percha  paper  on  which 
dry  sublimated,  borated  or  iodoform  gauze  is  placed;  and  to  im- 
mobilize this  an  ordinary  roller  may  be  used.  Some  operators 
have  simplified  the  dressing  by  merely  sprinkling  iodoform  over 
the  grafted  surface;  yet  some  retentive  appliance  is  preferable, 
since  the  grafts  are  easily  displaced  from  their  site.  Should  such 
displacement  occur  from'  tlie  patient's  movements,  the  grafts 
should  be  restored  to  j^osition  again. 

In  one  week  the  grafts  contract  close  adhesion  to  the  subjacent 
ground  ;  and  two  weeks  after  the  grafting  the  healing  is  complete. 
FoT  two  weeks  after  the  healing  a  protective  banda,ge  should  be 
retained  about  the  part. 

The  surface  which  has  been  closed  with  skin-grafts  tends  to 
contract,  and  to  rise:  thus  the  site  of  the  breach  is  lessened,  and 
if  it  be  superficial,  it  may  rise  to  a  level  with  the  surrounding 
skin.  In  healing,  the  transplanted  material  becomes  discolored 
or  slightly  pigmented,  so  that  it  differs  in  hue  from  the  neighbor- 
ing skin.  The  transplanted  surface  is  less  smooth  than  normal 
skin;  and  this  unevenness  is  due  to  granulative  elevations  which 
appear  under  the  grafts  during  the  i^rocess  of  healing.  Slight 
furrows  are  present  along  the  lines  of  fusion  of  adjacent  grafts. 

The  engrafted  surface  does  not  corresj)ond  in  color  to  the 
adjacent  skin;  it  is  distinguished  by  an  injected  pigmentary 
appearance;  and  this  is  a  serious  objection  to  the  Thiersch  method 
in  cases  in  which  the  cosmetic  element  must  be  taken  into 
account.  But  the  j^lastic  methods  before  described  are  free  from 
this  objection,  since  the  normal  skin  which  is  used  for  closure 
nearly  or  quite  retains  its  natural  tint.  A  point  strongly  in 
favor  of  the  Thiersch  procedure  is  that  closure  is  very  speedily 
obtained;  the  work  is  accomplished  within  two  weeks.  The 
other  plastic  procedures  often  require  many  weeks  for  complete 
recovery. 

Therefore,  in  conclusion  of  this  subject,  it  may  be  said  that. 


454  THE    ELEMENTS    OF    PLASTIC    SURtiERY. 

though  the  Thiersch  method  lias  seriously  encroached  on  the 
older  plastic  procedures,  yet  the  latter,  though  less  often  resorted 
to  than  formerly,  must  still  continue  to  occupy  a  highly  impor- 
tant place  in  operative  surgery.  And  this  is  particular!}-  true 
in  operative  work  on  the  face;  and  es|)ecially  in  the  repair  of 
breaciies  made  by  excision  around  the  eye,  mouth  and  nose;  for 
here  the  experienced  plastician,  by  studied  plan,  can  often  cover 
or  disguise  unsightly  lines  left  by  the  scalpel;  or  if  this  be  denied, 
then  such  lines  may  sometimes  be  so  shifted  as  to  be  invisible. 
By  such  work  the  plastician  will  win  parental  gratitude  by  re- 
lieving the  face  of  childhood  of  unsightly  scars;  and  surgical  art 
will  gratify  age  when  it  utilizes  the  latter's  furrows  for  plastic 
disguises. 


CHAPTER  XII. 


SURGICAL    AFFECTIONS    OF    THE    EYEBROWS    AND    EYELIDS. 

Eyebrow. — The  overhanging  skeleton  of  the  orbit  above  is  em- 
braced in  what  is  designated  the  superciliary  arch.  The  anterior 
inferior  edge  of  this  arch,  named  the  supra-orbital  margin,  is  formed 
by  the  union  of  the  supra-orbital  plate  and  the  vertical  portion  of 
the  OS  frontis:  this  margin  ends  so  sharply  that  violence  acting 
on  the  soft  parts  which  rest  on  the  edge,  can  cause  a  lesion  closely 
resembling  an  incised  wound;  and  to  determine  whether  the 
wound  which  lias  arisen  may  have  been  caused  by  a  cutting 
instrument,  or  by  the  osseous  margin  through  forcible  impact  on 
it,  has  sometimes  become  a  question  difficult  of  decision.  This 
margin  near  its  middle  presents  a  notch  or  foramen,  through 
which  passes  the  frontal  nerve  in  its  ascent  towards  the  vertex  of 
the  head.  The  outer  end  of  the  supra-orbital  ridge  terminates  in 
the  external  angular  process,  three-sided  and  prismoidal  in  form, 
of  which  the  thin  edge  is  directed  inwards,  and  separates  the 
orbit  here  from  the  temporal  fossa.  This  prismoidal  process  by 
its  outer  broad  and  strong  face  becomes  a  protective  bulwark  of 
the  eye;  yet  a  missile  or  thin  blade  might  readily  pierce,  from  the 
temporal  side,  the  deeper  thin  edge  of  the  process. 

The  soft  parts  which  lie  on  tlie  superciliary  arch  have  a 
resemblance  to  the  hairy  scalp;  from  without  inwards  lie  the 
derm  containing  hair,  the  muscular  structure,  a  sub-muscular 
layer  of  connective  tissue,  and  the  periosteum.  To  the  dermal 
layer  containing  hairs  the  name  eyebrow  is  given,  the  inner, 
middle  and  outer  parts  of  which  by  the  French  writers  are  named 
the  head,  body  and  tail  of  the  brow.  The  hair  on  the  head  or 
inner  part  of  the  brow  lies  pointing  upwards;  the  remaining 
hairs  point  obliquely  outwards.  The  glabella  or  hairless  space 
between  the  brows  ma}'  be  so  encroached  on  by  the  hair  that  the 
two  brows  are  continuous  across  the  space  over  the  root  of  the 
nose.  Or  the  brow  hairs  may  be  so  sparse  as  to  deform  the  coun- 
tenance.    The  surgeon  may  utilize  the  brow  hair  to  mask  scars 

(  455 ) 


456  AFFECTIONS   OF    THE    EYEBROWS    AND    EYELIDS. 

which  are  made  in  tlie  removal  of  small  tumors  seated  under  or 
near  the  superciliary  derm.  For  this  purpose,  the  brow  should 
first  be  shaven,  the  growth  removed  through  a  horizontal  cut, 
and  the  latter  accurately  closed  by  a  temporary  suture.  Aseptic 
precautions  must  be  used  against  suppuration,  for  if  the  latter 
occurs,  hair  roots  will  be  destroyed,  and,  as  result,  both  scar  and 
absent  hair  will  stigmatize  and  avenge  careless  procedure.  The 
brow  encroaching  on  the  glabella  renders  the  derm  here  unsuited 
for  transplantation  on  the  side  of  the  nose. 

Three  muscles  unite  in  the  formation  of  the  muscular  layer, 
viz.,  the  frontal  slij)  of  the  occipito-frontal,  the  corrugator  and  the 
orbicular  muscle.  The  commingled  structure  of  these  muscles 
is  so  closely  connected  with  the  skin  that  only  by  forced  dissection 
can  one  separate  the  two:  incision  through  the  derm  alone  gapes 
so  little  as  not  to  require  suture;  yet  if  the  muscular  coat  be 
divided,  sutural  closure  is  necessary  after  shaving  the  hair.  The 
corrugator  muscles  fold  the  intervening  derm  vertically;  and 
incisions  made  here  for  any  purpose,  should  lie  in  the  infolded 
lines.  Of  the  three  muscles  here  lying  the  orbicularis  is  outside, 
the  occipito-frontal  intermediate,  and  the  corrugator  lies  deei)est. 

Beneath  the  muscular  structure  lies  a  loose  cellular  structure 
which  is  continuous  with  the  sub-aponeurotic  layer  of  loose  tissue 
in  the  scalp.  This  loose  couch  allows  the  superjacent  structures 
to  move  freely  over  it.  Here  pus  or  blood  may  insinuate  itself 
and  travel. 

Beneath  the  layer  of  loose  tissue  lies  the  periosteum,  which  is 
closely  adherent  to  the  frontal  bone,  and  continues  into  the  orbital 
cavity,  lining  the  supra-orbital  plate;  and  with  it  fuse  the  palpe- 
bral ligaments. 

The  soft  structures  of  the  brow  have  an  ample  sui)ply  of  blood: 
externally,  from  the  anterior  temporal ;  at  their  middle  portion 
the  frontal  artery  reaches  them  through  the  supra-orbital  foramen 
ornotch;  and  internally,  the  supply  is  from  the  nasal  branch  of 
the  internal  carotid.  In  consequence  of  its  abundant  supply  of 
blood  the  structure  of  the  brow  bleeds  freely  when  it  is  cut;  the 
arrest  of  the  hiemorrhage  is  best  done  by  means  of  sutures  or 
circumscriptive  ligature;  the  latter  is  best  adaj)ted  for  the  con- 
trol of  haemorrhage  from  the  anterior  temporal  artery. 

The  vascularity  of  the  brow  favors  swelling  in  case  of  contu- 
sion or  subcutaneous  laceration.  A  clot  thus  forming  may  remain, 
and,  becoming  organized,  it  can  disfigure  the  part,  since,  besides 
the  induration  which  mav  remain,  the  hair  roots  of  the  brow 


EYEBROW.  457 

may  be  destroyed  and  a  naked,  swollen  point  remain;  and  hence, 
though  but  an  unimportant  wound,  such  contusion  should  be 
carefully  treated  by  cold  and  compressive  bandage. 

The  region  of  the  eyebrow  is  seldom  the  site  of  origin  of  a 
malignant  growth;  and  though  epithelioma  may  appear  there,  it 
is  rather  as  a  secondary  development  than  as  a  primary  growth. 
Cancer  arising  on  the  bulb  of  the  eye  or  on  the  lids,  in  its  pro- 
gressive devastation,  may  invade  and  destroy  the  superjacent  brow. 
The  treatment  in  such  a  case  should  be  excision  or  cauterization, 
and  to  be  effective  should  be  thorough  and  unsparing. 

Of  the  forms  of  benign  growths  which  appear  here,  the  most 
common  are  the  atheromatous  or  sebaceous  cyst,  and  the  dermoid 
cyst.  The  dermoid  cyst  is  often  seen  beneath  the  outer  end  of 
the  brow,  resting  on  the  external  angular  process.  Its  frequent 
appearance  here  is  accounted  for  by  the  circumstance  that  in  this 
part  of  the  head  there  exists  in  embryotic  development  a  bran- 
chial cleft,  or  gap  between  the  primordial  plates  of  the  tempero- 
frontal  region.  Through  some  inexplicable  contingency,  a  point 
of  cutis  becomes  caught  in  this  gap,  and  becomes  covered  beneath 
the  periosteum.  The  imprisoned  dermal  fragment  contains  the 
elements  of  hair,  sebaceous  glands  and  other  cuticular  compo- 
nents. These  elements  continue  their  development,  and  thence 
arises  the  content  of  the  tumor,  consisting  of  hair,  sebaceous 
material  and  epidermal  scales,  the  quantity  of  material  and 
volume  of  the  cyst  being  probably  j)roportional  to  the  primary 
fragment  of  included  cutis. 

This  dermoid  growth  is  soft  and  lies  in  a  depression  of  the 
bone,  beneath  the  periosteum.  Its  situation  beneath  the  perios- 
teum renders  the  cyst  nearly  immovable.  The  cyst  wall  is  dense 
and  strong.  It  is  important  to  distinguish  this  growth  from  the  se- 
baceous cyst;  the  following  characteristics  distinguish  the  dermoid 
cyst:  it  lies  deep,  cannot  be  moved  laterally,  and  is  depressible. 
On  the  contrary,  the  sebaceous  cyst  lies  less  deep,  can  be  caused 
to  slide  laterally  beneath  the  skin,  and  is  of  firmer  consistence 
than  the  dermoid  growth.  In  a  few  cases  which  the  writer  has 
observed,  it  was  impossible  to  determine  the  nature  of  the  tumor 
until  it  was  removed ;  in  one  case,  sebaceous  content  was  found 
where  the  differential  diagnosis  had  indicated  a  dermoid  cyst. 

The  treatment  of  each  species  is  extirpation ;  and  this  is  more 

strongly  indicated  in  the  sebaceous  cyst  than  in  the  dermoid;  for 

the  former  tends  to  reach  a  larger  volume  than  the  latter,  which 

often  remains  of  small  size.      The  removal  of  the  sebaceous 

30 


458  AFFECTIONS    OP    THE    EYEBROWS    AND    EYELIDS. 

species  is  done  here,  as  on  the  scalp,  by  a  simple  incision  in  the 
long  axis  of  the  brow,  through  which  the  content  is  extracted; 
and  with  this  should  also  be  removed  the  filmy  structure  of  tis- 
sue in  Avhich  the  material  is  included.  If  tlie  dermoid  cyst  is 
small,  and  hence  but  slightly  conspicuous,  and  has  remained 
without  further  growth  for  a  long  period,  it  is  better  not  to  inter- 
fere with  it.  But  if  it  be  so  large  as  to  be  unsightly,  then  it 
should  be  removed;  and  the  removal  is  still  more  imperative  if 
the  tumor  is  growing.  This  extirpation  is  done  through  an 
incision  made  in  or  below  the  longitudinal  axis  of  the  brow; 
and  this  cut  may  sometimes  be  made,  if  the  skin  be  drawn 
upwards,  in  the  eyelid  near  the  supra-orbital  margin;  in  this  site 
the  resultant  scar  may  lie  in  a  natural  sulcus  of  the  surfoce.  If 
some  tact  be  needed  to  open  and  remove  without  rupture  the 
content  of  a. sebaceous  cyst,  there  is  still  more  care  required  to 
successfully  extirpate  the  dermoid  cyst.  The  entire  cystic  wall 
must  be  removed ;  a  fragmentary  portion  of  it  left  insures  a 
recurrence  of  the  growth  in  a  more  complicated  form;  the  cicatri- 
cial tissue  and  adhesions  will  render  another  removal  much  more 
difficult  than  the  first  one.  Hence,  through  a  horizontal  free  cut, 
which  has  not  opened  the  cyst,  the  latter  must  be  dissected  from 
its  connections.  Since  the  cyst  is  adherent  to  the  periosteum, 
which  is  fused  with  the  including  sack,  an  incision  to  the  bone, 
circumscribing  the  growth,  should  be  made,  and  then  the  cyst, 
along  with  a  periosteal  segment,  may  be  detached  from  the  bone. 
The  wound  should  be  closed  by  sutures,  and  a  small  drainage 
tube  or  thread  sliould  be  so  placed  in  the  middle  of  the  wound 
that  any  excreta  may  easily  escape.  In  one  case  seen  by  the 
writer,  in  which  drainage  had  been  badly  done,  final  closure  was 
only  secured  by  reopening  the  wound,  curetting,  and  allowing  the 
part  to  heal  from  within  outwards.  Removal  of  the  thread  or 
tube  used  should  be  done  as  soon  as  the  excreta  cease  to  appear. 
The  brow  is  sometimes  the  site  of  black  pigmentation;  and 
with  this  discoloration  there  may  be  a  grow^th  of  hair  similar  to 
that  of  the  hair  of  the  scalp.  Two  instances  of  the  kind,  orig- 
inating congenitally,  have  been  seen  by  the  writer.  The  skin 
was  of  Nubian  blackness.  In  each  case  the  trouble  was  unilateral, 
md,  besides  the  brow,  one  side  of  the  frontal  integument  was 
implicated.  The  treatment  consisted  in  each  case  in  the  removal 
of  the  discolored  tissue,  and  partial  closure  of  the  breach  made, 
by  lateral  sliding  of  the  adjacent  derm.  As  the  children  grew, 
the  immense  scar  became  less  in  its  dimensions,  and  the  cica- 
tricial tissue  was  free  from  pigmentation. 


EYELID.  459 

Eyelid. — Anatomically,  the  eyelids  consist  of  an  upper  and  a 
lower  one;  the  upper  descends  so  far  that  it  may  conceal  too  large 
a  gap  made  by  iridectomy;  also  in  cases  in  which  the  protective 
action  of  the  lower  lid  has  been  lost  through  loss  of  the  lower 
lid,  the  upper  one  when  turned  downwards  can  nearly  cover  the 
globe.  Each  eyelid,  near  the  osseous  margin  of  the  orbit,  presents 
a  depression  or  sulcus;  the  superior  one  is  deeper  and  is  some- 
times masked  by  an  overhanging  cuticular  fold,  especially  in  the 
aged. 

The  free  edges  of  the  lids  are  named  their  ciliary  borders,  and 
inclosure  of  the  lids  these  borders  are  closely  apposed,  and  do  not 
leave  an  intervening  space  for  the  passage  of  tears,  as  some  have 
taught.  The  lower  border  of  the  upper  lid  is  slightly  curved, 
while  that  of  the  inferior  is  slightly  concave.  On  the  free  margin 
of  the  lids  one  can  distinguish  near  the  outer  edge  the  insertion 
of  the  eyelashes,  of  which  there  are  from  one  hundred  to  one 
hundred  and  fifty  on  each  lid;  and  near  the  inner  border  there 
are  seen  the  openings  of  the  Meibomian  glands;  and  there  is  an 
interstice  between  the  cilia  and  the  openings  of  the  glands  wide 
enough  for  division  with  the  knife  of  the  free  border  into  two 
portions.  About  one-eighth  of  the  free  border  towards  the  nose 
is  occupied  by  the  lachrymal  canaL  At  the  junction  of  the 
ciliary  with  the  lachrymal  portion  of  tlie  free  border  is  a  small 
opening  which  leads  into  the  lachrymal  canaL  The  angular 
union  of  the  free  borders  of  the  lids  externally  is  nam^ed  tlie 
external  canthus;  the  inner  one  is  named  tlie  inner  canthus.  In 
the  inner  canthus  the  conjunctiva  and  the  cutis  unite  directly, 
without  depression. 

The  component  strata  of  the  eyelid,  if  enumerated  from  with- 
out inwards,  present  themselves  in  the  following  order:  the  skin, 
the  orbicular  muscle,  layer  of  loose  connective  tissue,  the  tarsal 
cartilage  and  ligament,  fibro-tendinous  layer  and  the  conjunctiva. 

The  dermal  layer  is  thin,  pliant  and  easily  moved;  it  contains 
rudimentary  hairs  and  sebaceous  and  sudoriferous  glands.  The 
movement  of  the  subjacent  parts  wrinkles  this  dermal  surface; 
the  folds  and  depressions  thus  formed,  from  their  frequent  repro- 
duction, become  permanent  features  of  the  aged,  and  senility 
when  prompted  with  the  desire  of  self-concealment,  does  not 
forget  those  markings,  yet  is  seldom  successful  in  hiding  the 
footsteps  which  time  imprints  most  deeply  at  the  outer  edge  of 
the  eye.  The  mobile  nature  of  the  palpebral  cutis  is  often  util- 
ized in   surgical  work  in  this  region.     This  mobility  may  act 


460  AFFECTIONS    OF    THK    EYEBROWS    AND    EYELIDS. 

injuriously;  for  in  the  case  of  a  wound  near  the  eyelid,  which  is 
followed  by  cicatricial  contraction,  the  skin  may  be  drawn  upon 
so  as  to  displace  it,  and  prevent  the  closure  of  the  eye. 

The  palpebral  orbicular  muscle  is  a  species  of  sphincter  that 
is  concerned  in  the  automatic  act  of  wrinkling  and  closure  of  the 
lids.  It  is  a  cutaneous  muscle  lying  next  to  the  skin.  It  is  pale 
in  color,  especially  as  it  approaches  the  free  borders  of  the  lids; 
and  here  the  non-striated  or  involuntary  muscular  fibre  is  found. 
The  half  of  the  muscle  which  lies  on  the  lower  lid  is  thicker  and 
stronger  than  the  upper  half,  since  the  former,  in  the  act  of 
closure,  has  more  work  to  do.  In  closing,  the  edge  of  the  lower 
lid  moves  towards  the  inner  angle;  this  inward  movement,  which 
can  be  verified  by  a  vertical  line  drawn  on  the  united  lids, 
amounts  to  over  a  line  in  distance.  Such  movement  serves  the 
purpose  of  carrying  towards  the  inner  angle  tears,  or  particles  of 
foreign  matter,  lodged  in  the  eye.  The  palpebral  sphincter  may 
become  the  subject  of  continued  or  intermittent  spasm, and  become 
a  source  of  annoyance  or  pain.  From  contracture  of  the  muscle, 
a  fold  of  skin  may  be  drawn  over  the  outer  angle;  and  in  the 
little  pouch,  thus  formed,  irritating  matter  can  collect  and  denude 
the  edge  of  the  lid,  and  cause  adhesion  and  shortening  of  the 
angular  commissure.  In  the  aged  the  muscle  becoming  weak- 
ened, the  skin  of  the  lid  depends,  that  of  the  lower  lid  sinking 
towards  the  cheek  and  causing  an  apparent  tumefaction  there; 
this  appearance  is  specially  marked  in  the  portrait  of  Dr.  Frank- 
lin taken  in  his  old  age.  In  the  upper  lid  such  pendent  tegument 
may  fall  within,  and  obstruct,  the  range  of  vision ;  so  much  so 
that  the  subject  is  compelled  to  lift  the  fold  with  his  hand,  in 
order  to  obtain  free  vision ;  but  the  screen  may  be  retained  in 
place  by  a  strip  of  adhesive  plaster. 

The  muscularity  of  the  lids  is  innervated  by  the  motor  oculi 
and  the  facial  nerve;  the  sphincter  is  moved  by  the  latter,  which, 
in  its  transit  from  the  parotidean  region  to  the  eye,  lies  beneath 
the  subcutaneous  fascia;  and  thus  this  twig  of  the  facial  often 
escapes  the  knife  in  superficial  excisions  made  in  this  region. 
But  palsy  of  the  nerve  from  division  of  it,  or  other  cause,  permits 
the  downward  sliding  of  both  skin  and  muscle  in  both  lids,  and 
in  the  upper  one,  the  dependent  skin  soon  interferes  with  the  due 
admission  of  light.  The  subfascial  site  of  the  facial  twig 
referred  to,  which  the  author  has  verified  by  dissection,  should  not 
lessen  care  in  the  use  of  the  knife  here;  yet  it  allows  the  indul- 
gence of  the  hope  that  when  incision  is  done  here,  the  nerve  may 
be  spared. 


EYELID.  .  461 

Beneath  the  orbicular  muscle  there  lies  a  layer  of  loose  areolar 
tissue,  which,  similar  to  one  existing  in  the  scalp,  permits  of  the 
free  motion  of  the  superjacent  layer  on  the  subjacent  tarsal  car- 
tilage; and  in  this  yielding  space  fluent  materials,  as  blood  and 
serum,  may  diffuse  themselves;  and  the  supjDurative  products  of 
phlegmonous  inflammation  may  also  travel  here.  Beneath  the 
lax  structure  of  areolar  tissue  of  the  evelid  lie  the  tarsal  cartilap:e 
and  the  tarsal  ligament.  The  palpebral  cartilages  aid  in  main- 
taining the  curved  form  of  the  lids;  that  of  the  upper  lid  is  much 
the  stronger  one;  it  is  crescenticin  form  and  is  comparable  to  a  sec- 
tion of  an  orange.  The  superior  one  measures  about  one-third  of 
an  inch  at  the  point  of  its  greatest  breadth.  The  lower  cartilage 
is  quadrilateral  in  form.  These  two  cartilages,  at  their  outer 
borders,  become  converted  into  a  fibrous  ligamentous  structure, 
which,  for  each  cartilage,  radiates  towards  the  orbit  where  it  is 
inserted.  This  fibrous  structure  in  the  upper  and  lower  lid  is 
named  the  palpebral  ligament ;  and  the  two,  at  the  inner  and 
outer  commissure,  converge,  and,  uniting,  form  the  inner  and 
outer  palpebral  tendons,  which  can  readily  be  found  and  brought 
respectively  into  relief,  if  the  lids  be  drawn  horizontally  inwards 
or  outwards.  The  inner  tendon  is  the  greater  one ;  it  is  the  tendon 
of  the  orbicularis  muscle  as  well  as  of  the  tarsal  cartilages,  and 
should  be  known  to  the  surgeon,  since  it  lies  across  the  lachry- 
mal sack. 

This  fibro-cartilaginous  framework  of  the  lids  may  be  better 
understood  when  it  is  stated  that  the  tarsal  cartilages  commenc- 
ing at  tlie  border  of  the  lid,  after  forming  a  supporting  framework, 
become  changed  into  fibrous  tissue,  which  at  each  end  forms 
rounded  tendons;  while  between  these  lie  intermediately  the 
tarsal  ligaments,  so  that  each  lid  is  firmly  connected  by  this 
ligament  to  half  the  circumference  of  the  orbit.  AVhere  the 
cartilages  lie,  the  lid  is  not  easily  bent  or  curved,  but  such  flexion 
can  be  made  at  the  orbital  border  of  the  tarsal  cartilage;  and  by 
virtue  of  this  disposition,  the  lids  may  be  everted  so  as  to  expose 
the  inner  surface.  The  eversion  of  the  upper  lid  is  more  readily 
done  than  is  the  case  with  the  lower  one.  To  effect  this  eversion, 
seize  the  eyelashes,  or  lower  margin  of  the  lid,  with  one  hand, 
and  with  the  other  hand  let  some  blunt  instrument,  as  a  silver 
probe,  or  handle  of  a  pencil,  be  fixed  against  the  lid  at  the  junc- 
tion of  the  tarsal  cartilage  and  its  broad  ligament;  and  pressure 
being  made  there  as  the  free  border  is  pulled  on,  the  lower  half  of 
the  lid  is  easily  everted.     Or  the  eversion  can  be  effected  without 


4G2  AFFECTIONS    OF    THE    EYKliKOWS    AND    EYELIDS. 

any  instrument  by  catcliing  the  ciliary  border  with  one  hand, 
and  as  tliis  is  pulled  outwards,  let  a  linger  of  the  other  hand 
press  backwards  on  the  middle  of  the  outer  face  of  the  lid; 
iu  "whatever  way  the  work  is  done,  the  patient  during  the  act 
must  direct  his  eye  downwards.  In  fact,  the  junction  of  the 
tarsal  cartilage  and  the  broad  palpebral  ligament  of  the  upper 
eyelid,  serves  in  the  eversion  just  described,  the  office  of  a  joint. 
The  broad  palpebral  ligament  permits  the  normal  movements  of 
the  lids;  and  when  the  latter  are  closed  for  many  hours,  a  condi- 
tion simulating  anchylosis  is  felt  by  the  sleeper  on  awakening. 

The  conjunctival  mucous  membrane  that  lines  the  inner  face 
of  the  lids,  as  well  as  a  large  zone  of  the  bulb  of  the  eye,  forms  a 
blind  recess  or  fossa  between  the  lids  and  the  globe  of  the  eye. 
The  upper  recess,  or  transition  fold  of  the  conjunctiva,  is  much 
the  deeper  one,  and  demands  the  attention  of  the  surgeon,  as  in 
this  hidden  fold  foreign  bodies  may  lodge  and  remain  undiscov- 
ered. Also,  a  growth  in  the  upper  part  of  the  orbit  may  here 
make  its  primary  appearance.  The  eversion  of  the  upper  lid 
and  turning  the  eye  downwards  greatly  lessen  the  depth  of  the 
upper  fossa,  and  reveal  anything  which  may  exist  there.  Also, 
by  drawing  the  lower  lid  downwards  when  the  globe  is  rolled 
upwards,  one  will  display  the  content  of  the  lower  conjunctival 
fold.  A  neglect  to  carefully  unfold  and  search  to  its  bottom  tlie 
conjunctival  fosste  has  permitted  a  foreign  body  to  lie  hidden 
and  continue  its  work  of  irritation,  until  a  suppuration  was 
induced,  which  only  ended  with  corneal  destruction  and  loss  of 
vision.  And  should  the  lid  be  so  swollen  that  it  cannot  easily  be 
everted,  then  the  work  should  be  preceded  by  local  anajstliesia 
with  cocaine,  or,  what  is  more  satisfactory  if  the  case  be  a  cliild, 
general  anaesthesia. 

On  the  inner  edge  of  the  margin  of  the  lids  lie  the  outlets  of 
the  Meibomian  glands.  These  glands,  akin  in  function  to  the 
sebaceous,  lie  imbedded  in  the  tarsal  cartilages,  much  nearer  to 
the  conjunctival  face  than  to  the  dermal  surface  of  the  lid. 

The  bulbar  conjunctiva  can  be  easily  moved  on  the  eyeball; 
the  palpebral  conjunctiva  is  more  firmly  adherent;  the  mobility 
of  the  former  may  be  utilized  in  o[)erative  work  on  the  eyeball. 

The  veins  of  the  lids  empty  their  blood  partly  into  the  facial 
vessels  and  partly  into  the  ophthalmic,  which  enters  the  cranium 
and  opens  into  the  cavernous  sinus:  and  through  this  venous 
route,  septic  or  infectious  materials  can  travel  and  develop  disease 
within  tlie  skull.     The  lymphatics  of  the  lids  and  the  conjunctiva 


WOUNDS    OF    THE    EYELIDS.  463 

deliver  their  contents  to  the  parotidean  lymphatic  glands;  as  re- 
sult of  such  anatomical  disposition,  malignant  disease  of  the 
eyeball  or  lids  may  reveal  itself  by  glandular  swelling  in  the 
parotid,  the  so-called  parotidean  bubo.  Specific  ocular  disease 
may  have  a  similar  distal  manifestation.  The  lymphatics  of  the 
inner  angle  of  the  eye  pass  to  a  gland  situated  on  the  masseter 
muscle,  sometimes  named  the  facial  gland. 

In  regard  to  the  embryonic  development  of  the  eye  it  may 
be  briefly  mentioned  that,  at  the  second  month  of  uterine  life,  a 
layer  of  the  epiblastic  la3'er  passes  over  the  eye,  becoming  the 
conjunctiva.  In  the  third  month,  another  layer,  in  plicated 
annular  form,  surrounds  the  eye,  and  gradually  grows  by  concen- 
tric development  until  it  covers  the  eye.  The  edges  of  these 
primitive  lids  fuse  together  and  remain  so  until  two  months 
before  birth.  The  normal  ty23e  may  be  deviated  from  in  this  work 
of  fusion  and  separation. 

Since  the  advent  of  the  period  when  general  surgery  has  been 
differentiated  by  specialism,  the  treatment  of  the  diseases  of  the 
eye  has  fallen  mainly  to  the  hand  of  the  oculist:  nevertheless, 
the  eyelid  has  remained  a  field  shared  in  common  by  the  special- 
ist and  surgeon,  the  latter  having  the  larger  share  when  one 
reckons  the  plastic  operative  work  demanded  by  disease  and 
defect  of  the  eyelid. 

Wounds  of  the  Eyelids. — The  eyelids  may  be  the  site  of  any 
species  of  wound;  those  occurring  most  often  are  the  contused, 
lacerated,  incised  and  penetrating. 

The  protective  bulwark  of  the  superciliary  arch  usually 
receives  the  violence  which  otherwise  might  impinge  on  and  con- 
tuse the  eyelid.  A  contusion  of  the  brow  or  of  the  cheek  near  by, 
in  its  effects,  often  extends  to  the  contiguous  lids.  The  character- 
istics of  contusion,  whether  it  arises  directly  or  indirectly,  are 
swelling  and  diflPusion  of  extravasated  blood.  There  are  present 
swelling  from  effused  blood,  and  oedema  due  to  obstruction  of  the 
lymphatics  through. diminution  of  their  calibre  by  elongation  or 
lateral  pressure.  The  ecchymosed  blood  finds  space  for  its  diffu- 
sion immediately  underneath  the  skin,  and,  especially,  in  the 
distensible  space  between  the  muscular  and  fibro-cartilaginous 
layers.  A  disagreeable  concomitant  attendant  on  this  effusion  of 
blood  is  that  the  blood  penetrates  the  skin  and  becomes  visible  on 
the  surface.  The  bluish,  livid  or  blood-stained  hue  of  the  cutis, 
though  unfelt  by  the  patient,  annoys  the  latter  far  more  than  the 
contusion  itself.    The  sanguineous  and  serous  effusion  often  swells 


464  AFFECTIONS    OF    THE    EYEBROWS    AND    EYELIDS 

the  lid  to  such  dimensions  that  it  hangs  as  a  motionless  veil, 
closing  the  eye,  and  wholly  obstructing  vision.  And,  what  is 
remarkable,  the  source  of  such  efi'used  blood  may  be  ruptured 
vessels  situated  at  some  distance,  in  the  supra-orbital,  temporal  or 
malar  region;  in  the  latter  case  the  blood  travels  upwards. 

Palpebral  ecchymosis  may  be  symptomatic  of  a  more  remote 
injury:  viz.,  it  may  arise  from  fracture  at  the  base  of  the  cranium, 
in  which  the  escaping  blood  travels  through  the  sphenoidal  fis- 
sure, and  appears  iu  the  eyelids.  And  the  distinction  between 
this  form  of  ecchymosis  and  that  which  results  from  local  injury 
of  the  lid,  is  this,  that  blood  proceeding  from  fracture  of  the 
cranial  base  only  presents  itself  some  hours  after  the  injury, 
while  in  the  other  case  the  ecchymosis  occurs  immediately. 
Hence,  as  seen,  one  may  divide  palpebral  ecchymosis  into  two 
species,  primitive  and  consecutive.  The  tardy  §.upervention  ,of 
the  consecutive  species  indicates,  very  probably,  an  intra-cranial 
injury  perilous  to  the  patient's  life.  Such  symptomatic  ecchy- 
mosis occurs  oftener  in  the  lower  than  in  the  upper  eyelid,  since 
the  former  lies  more  directly  in  the  course  of  gravitation;  on  the 
contrary,  primitive  ecchymosis  appears  equally  in  each  lid. 

In  case  of  severe  contusion  of  the  lid,  there  may  be  a  pouch- 
like collection  resembling  a  haematoma;  such  contusion  is  seen 
in  the  prize-fighter;  and  the  swelling  may  so  obstruct  his  vision 
that  he  is  compelled  to  seek  relief  from  the  surgeon. 

The  contused  wound  is  treated,  in  the  early  stage,  by  massage, 
compression  and  cold  application.  After  the  effused  blood  has 
been  somewhat  dissipated  by  cautious  kneading,  compression 
should  be  made  by  means  of  compresses  retained  in  place  by  a 
bandage  encircling  the  head,  horizontally.  And  the  part  may 
be  maintained  cold  by  moistening  the  compress  with  ice-water, 
or  a  small  bag  of  crushed  ice  may  be  laid  over  the  part.  The 
cold  must  not  be  used  to  excess,  lest  the  contused  tissues, 
enfeebled  as  they  are  by  impaired  supply  of  blood,  should  die. 
Medicated  solutions,  which  are  elsewhere  used  to  reduce  swelling 
from  contusion,  are  inapplicable  here,  since  they  would  come  in 
contact  with  and  injure  the  eyeball.  After  three  or  four  days, 
when  the  active  stage  has  passed,  the  absorption  or  dispersion  of 
the  ecchymosed  blood  will  be  hastened  by  an  exchange  of  cold 
for  warm  applications;  and  for  this,  tepid  water  should  be  used, 
applied  by  compresses. 

If  the  lid  be  the  site  of  a  hfematoraa-like  collection  of  blood, 
as  seen  in  the  boxer's  eye,  the  effused  blood  must  be  evacuated  by 


WOUNDS    OP    THE   EYELIDS.  465 

an  incision  through  the  skin  of  the  lid,  made  horizontally  or 
parallel  with  the  fibers  of  the  orbicular  muscle.  After  the  blood 
is  thus  emptied,  the  lid  is  lessened  in  volume,  and  the  lips  of 
the  incision  close  without  suturing.  The  livid  stain  which 
remains  for  some  time,  as  the  result  of  palpebral  contusion,  is  to 
the  patient  the  most  disagreeable  accompaniment  of  his  con- 
tusion, since  nothing  but  the  fingers  of  time  can  erase  the  stain, 
and  the  work  of  erasure  passes  through  one  or  more  of  the  pris- 
matic colors,  viz.,  red,  green  and  yellow.  Nature  uses  leisure, 
and  her  own  convenience,  for  completing  the  task  of  obliteration. 
If  the  patient  be  a  female,  to  whom  such  discoloration  is  most 
repugnant,  a  recourse  may  be  had  to  the  artful  use  of  cosmetics, 
or  even  to  the  use  of  counterfeiting  pigments  applied  by  means 
of  the  painter's  brush. 

In  case  the  sanguineous  effusion  be  the  consecutive  result  of 
fracture  of  the  base  of  the  skull,  it  becomes  a  trustworthy  proof 
of  such  fracture;  its  treatment,  however,  is  a  thing  of  minor 
importance,  since  the  graver  injury  will  absorb  the  surgeon's 
attention. 

Contusion  of  the  lid  is  often  associated  with  a  lacerated 
wound;  and  the  presence  of  the  latter  will  lessen  the  tumefaction. 
Lacerated  and  contused  wound  here  should  be  treated  by  trim- 
ming the  fringe-like  edges,  so  as  to  change  it,  as  nearly  as 
possible,  to  the  form  of  an  incised  wound,  and  then  close  it  by 
sutures,  and  dress  with  cold  compresses. 

Incised  wound  of  the  lid,  if  superficial  and  parallel  with  the 
fibres  of  the  orbicular  muscle,  will  often  spontaneously  close,  and 
heal  without  the  aid  of  sutures;  should  there  be  gaping,  sutural 
closure  must  be  resorted  to  by  means  of  fine  silken  thread.  And 
in  all  cases  in  which  the  wound  lies  vertical,  to  prevent  the 
gaping  usually  then  present,  and  displacement  of  the.  edges, 
sutures  must  be  used.  Should  the  incised  wound  divide  the 
broad  ligament  of  the  lid,  then  union  must  be  effected  by  deep 
stitches  which  will  include  the  entire  thickness  of  the  lid,  and 
secure  accurate  union  of  the  parts.  Also,  in  case  the  levator 
palpebrse  superioris  be  severed,  so  that  there  is  ptosis  of  the  lid, 
then  accurate  sutural  coaptation  is  an  imperative  necessity;  and 
during  the  healing  of  the  divided  muscle,  as  also  in  the  case  of 
the  divided  broad  ligament,  the  lids  must  be  closed  and  retained 
at  rest. 

In  case  of  wounds  which  involve  the  border  of  the  lid,  closure 
must  be  so  effected  that  no  gap  will  subsequently  remain;  for  a 


466  AFFECTIONS    OF    THK    EYEBROW'S    AND    EYELIDS. 

slight  notch  there  is  a  deformity  which  attracts  attention.  To 
shun  this,  a  suture  should  be  placed  near  the  border,  both  on  the 
inner  and  outer  face  of  the  lid,  but  not  on  the  border  itself  If 
the  suture  include  the  border,  the  writer  has  seen  that  it  is 
certain  to  leave  some  trace  of  itself,  as  an  indentation. 

In  case  a  wound  implicates  any  portion  of  the  tear-conducting 
apparatus,  great  care  is  requisite  to  bring  the  parts  into  complete 
coaptation;  a  neglect  of  this  may  consign  the  patient  to  perma- 
nent epiphoral  annoyance.  A  wound  involving  the  border  of  the 
lower  lid  near  the  inner  cantlius,  allowed  to  heal  imperfectly, 
may  leave  a  gap  through  which  the  tears  will  escape  on  the  cheek; 
for  such  breach  in  the  M'all  of  the  "  tear-lake"  does  not  let  the 
tears  rise  to  a  level,  in  which  they  can  be  reached  by  the  mouths 
of  the  lachrymal  canalicules.  If  the  wound  has  not  healed,  close 
it  by  sutures  on  the  inside  and  outside;  but*if  healing  has 
occurred,  then  the  edges  of  the  gap  must  be  trimmed,  and  united 
by  sutures,  which  should  remain  in  site  for  a  week.  In  trim- 
ming the  cicatrized  border,  more  should  be  excised  from  the 
conjunctival  than  from  the  dermal  surface;  thus  done,  the 
tendency  to  ectropion  which  follows  such  closure  will  l)e  some- 
what corrected.  Nevertheless,  from  the  writer's  experience, 
despite  the  jiains  taken  there  remained  some  eversion  of  the 
border. 

Penetrating  wounds  which  are  limited  to  the  eyelids,  seldom 
occur;  the  wound  generally  passes  beyond  the  lid,  and  injures 
the  globe  of  the  eye;  and  in  some  cases  the  wounding  instrument 
or  missile  has  penetrated  still  deeper,  and,  having  passed  through 
the  walls  of  the  orbit,  or  the  sphenoidal  fissure,  has  entered  the 
cranial  cavity,  and  wounded  some  encepjialic  structure.  Thus 
the  middle  or  anterior  cerebral  lobe,  the  ophthalmic  vessels,  the 
internal  carotid  artery,  or  the  optic  nerve  may  be  injured.  An 
unfortunate  condition  which  attends  such  injury  is  that  the  mis- 
sile may  remain,  or  the  causal  instrument  ma}'  leave  its  point  in 
the  dangerous  site  mentioned.  Thus,  a  sharp  fragment  of  wood, 
a  needle's  point,  a  fragment  of  wire,  or  a  bullet  or  fine  shot,  may 
enter  and  lodge  in  the  eyeV)all  behind  or  outside  of  the  bulb;  or 
such  object  may  pass  into  the  cranial  cavity  and  produce  grave 
injury.  Even  though  the  traumatic  agent  l)e  witlidrawn,  if  it 
has  entered  the  cranial  cavity,  it  may  have  caused  a  tatal  wound 
of  the  brain.  The  history  of  surgical  curiosities  is  embellished 
with  examples  of  the  kind  mentioned. 

In  the  cases  in  which  foreign  bodies  have  entered  and  lodged 


ERYSIPELAS.  467 

behind  the  eyeball,  the  wound  on  the  lid  has  healed  quickly ; 
and  this  circumstance  has  deceived  both  patient  and  surgeon  in 
regard  to  the  extent  of  the  injury.  The  surgeon  should  endeavor 
to  discover  the  body  and  remove  it.  It  should  be  mentioned  that 
instances  have  occurred  in  which  the  body  has  remained,  become 
encysted,  and  caused  no  inconvenience  to  the  patient. 

Erysipelas. — Erysipelas  sometimes  appears  in  the  eyelid: 
either  primarily,  when  the  disease  commences  usually  in  the 
inner  canthus;  or  the  erysipelas  beginning  in  the  face  or  scalp,  by 
migration,  attacks  the  lid.  The  lid  swells  greatly  under  the 
action  of  erysipelatous  inflammation ;  and  an  unfortunate  event, 
which  sometimes  ensues,  is  suppuration.  In  cases  seen  by  the 
author,  the  disease  has  assumed  the  virulence  of  phlegmon  and 
caused  destruction  of  a  portion  of  the  lid.  The  sloughing  may 
be  limited  to  the  derm  and  muscle.  The  treatment  of  erysipelas 
here  consists  in  the  cautious  use  of  the  usual  local  remedies,  care 
being  taken  that  nothing  enters  the  eye  which  may  injure  it. 
An  ointment  containing  quinine,  in  the  proportion  of  two  grains 
to  an  ounce  of  vaseline,  may  safely  be  used  on  the  lid.  Should 
there  be  signs  of  suppurative  action,  haste  should  be  made  to 
open  and  evacuate.  Where  the  swelling  is  so  great  as  to  arrest 
the  blood  supply  and  cause  gangrenous  destruction,  this  may  be 
averted  by  pricking  the  surface  with  a  very  sharp  lance,  so  as  to 
give  exit  to  the  stagnant  blood,  and  thus  reduce  the  great  tume- 
faction, xlnd  as  a  topical  application,  a  decoction  or  cataplasm 
of  chamomile  flowers  may  be  used. 

Acute  abscess  occasionally  appears  in  the  eyebrow  and  eyelid, 
and  takes  a  course  similar  to  what  is  seen  elsewhere.  Chronic 
abscess  is  also  sometimes  seen,  and  is  often  connected  with  some 
morbid  process  in  the  tissues  surrounding  the  bulb,  or  in  the 
bony  wall  of  the  orbit,  or  parts  contiguous.  And  in  such  cases 
the  existence  of  the  pus  may  reveal  its  presence  by  a  swelling  at 
some  point  of  the  lid  near  the  margin  of  the  orbit.  Though 
such  pus  might  arise  from  caries  at  any  point  of  the  wall,  yet  it 
originates  oftener  in  the  upper  portion  of  the  orbit;  and  occa- 
sionally, the  disease  begins  in  the  frontal  sinus,  and,  perforating 
the  supra-orbital  plate,  appears  in  the  inner  half  of  the  upper 
lid.  In  a  case  seen  by  the  author  arising  from  disease  of  this 
sinus,  the  purulent  collection  had  for  its  anterior  wall  a  great 
part  of  the  upper  lid;  and  on  pressure  it  could  be  forced  back 
into  the  orbit,  but  caused  the  eyeball  to  prolapse  downwards 
and  forwards.     Such  chronic  abscess  in  its  development  causes 


468  AFFECTIONS   OF    THE    EYEBROWS    AND    EYELIDS. 

no  pain,  and,  were  it  not  for  the  swelling  which  it  causes,  it 
would  remain  undiscovered.  The  purulent  collection  may  remain 
without  increase  of  volume  or  other  ciiange  for  an  indefinite 
time. 

In  the  acute  abscess  it  suffices  to  open  and  evacuate  the  con- 
tents; but  in  the  chronic  form  mere  evacuation  would  soon  be 
followed  by  a  reaccumulation  of  the  content.  Hence,  to  accom- 
plish a  cure,  the  cavity  must  be  opened  freely,  and  the  point  of 
osseous  disease  must  be  searched  for,  found,  and  removed.  And 
to  do  this  some  exsection  of  the  orbital  wall  will  be  neces- 
sary; and  the  excision  of  bone  must  proceed  to  the  extent  of 
wholly  removing  the  diseased  structure.  If  this  removal  is 
imperfectly  done,  the  purulent  collection  will  soon  reapjjear. 
The  origin  of  the  intra-orbital  abscess,  as  stated  above,  is  some- 
times from  caries  within  the  frontal  sinus,  whence  pus  arising 
perforated  the  supra-orbital  plate.  When  tlius  arising,  it  is  nec- 
essary to  freely  open  the  sinus  through  its  antero-inferior  wall, 
and  remove  whatever  diseased  structure  is  discovered;  and  to 
make  sure  work,  as  before  described,  it  may  become  necessary  to 
excise  the  entirety  of  the  front  wall  of  the  sinus,  and  also  a  por- 
tion of  the  inferior  wall,  in  the  way  which  elsewhere  has  been 
described. 

Burns. — The  eyelid  may  be  the  site  of  burns,  and  these  may 
vary  from  the  innocently  mild  to  the  destructively  grave;  that 
is,  there  may  be  simple  rubefaction,  vesication,  or  the  lid  may  be 
partially  or  wholly  destroyed.  T])e  causal  agent  may  be  flame, 
boiling  liquid,  as  water  or  oil,  explosives,  and  molten  metal.  In 
severer  cases  the  burn  of  the  lid  is  the  less  important  lesion;  the 
graver  one  is  the  injury  of  the  eyeball,  which  may  be  so  burned 
as  to  impair  or  totally  destroy  vision. 

In  mere  rubefaction  or  vesication  of  the  lid,  the  only  treat- 
ment necessary  is  the  use  of  some  mild  local  application.  A 
favorite  remed}^  is  Linimentum  Calcis,  applied  on  lint  to  the  part. 
And  this  may  be  applied  to  more  severe  burns.  In  place  of  this, 
Unguentum  Cetacei  may  be  employed. 

In  cases  in  which  the  dermal  surface  is  destroyed,  as  the  part 
recovers,  the  cicatrizing  surface  contracts  and  induces  eversion  of 
the  lid;  an  important  part  of  treatment  is  to  antagonize  this  tend- 
ency. If  mere  vesication  is  present,  the  fibrinous  coagulum 
beneath  the  epiderm  should  not  be  disturbed,  and  thus  it  may 
be  possible  to  renew  the  normal  cuticle.  But  if  the  derm  be 
wholly  destroyed,  then  the  regenerated  surface  will  consist  of  con- 


EMPHYSEMA.  ^    469 

tractile  cicatricial  tissue,  with  persistent  tendency  to  shortening 
and  displacement.  To  counteract  this  something  may  be  done, 
if  during  the  early  stage  of  granulation  the  surface  be  covered 
with  cutaneo-epidermal  grafts.  And  instead  of  minute,  frag- 
mentary grafts,  the  method  of  Thiersch  might  be  resorted  to,  in 
which  large  portions  or  patches  of  dermo-epidermal  tegument 
may  be  used  for  implantation  on  the  raw  surface.  As  far  as 
practicable,  closure  of  the  eye  should  be  maintained  during  the 
time  of  healing.  Even  though  recovery  of  surface  in  normal 
form  may  ensue,  yet  there  usually  exists  a  tendency  to  eversion 
for  some  time.  This  may  be  counteracted  somewhat  by  gentle  mas- 
sage and  voluntary  movements,  in  which  the  eye  is  alternately 
widely  opened  and  closed,  motions  which  tend  to  maintain  the 
normal  breadth  of  surface.  In  case  healing  has  just  occurred 
and  contraction  is  ensuing,  the  shortening  may  be  lessened  by  a 
few  incisions  in  the  surface,  with  closure  of  the  lids,  and  their 
fixation  by  means  of  adhesive  strips  placed  vertically  and  hori- 
zontally; thus  disposed,  the  gaping  incisions  will  be  filled  with 
new  material,  and,  as  result,  the  surface  will  be  broadened. 

In  the  event  of  the  burn  having  destroyed  a  portion  of  the 
lid,  or  so  everted  it  that  the  eye  remains  permanently  open, 
then  some  plastic  procedure  must  be  resorted  to,  of  which  a 
description  will  appear  elsewhere. 

Emphysema. — The  eyelids  are  sometimes  the  site  of  emphysema, 
and  the  air  in  such  case  is  infiltrated  in  the  areolo-cellular  spaces 
of  the  lids.  The  cause  of  such  infiltration  of  air  is  to  be  sought  for 
in  a  fracture  of  bones  adjacent  to  the  eye;  such  fracture  may  be  of 
the  nasal  bones,  the  ethmoid,  the  frontal,  or  the  superior  maxil- 
lary bone,  in  which  a  cavity  or  sinus  communicating  with  the 
respiratory  passage  is  opened;  and  when  such  lesion  is  present, 
should  the  j^atient  make  a  violent  expiratory  effort,  as  in  the  act 
of  blowing  the  nose,  the  violently  compressed  air  may  enter  the 
loose  structure  of  the  lids.  The  statement  of  the  patient  usually 
is  that,  when  he  blew  his  nose,  the  lids  suddenly  swelled  and 
closed  the  eye.  The  entrance  of  the  air  is  attended  by  a  sudden 
twinge  of  sharp  pain.  In  some  cases  the  air  is  forced  backwards 
between  the  bulb  and  the  orbital  wall,  and  extrudes  the  bulb  for- 
wards, causing,  for  a  time,  exophthalmus.  The  author  once  wit- 
nessed the  supervention  of  such  emphysematous  swelling  of  the 
lids  of  one  eye,  and  displacement  of  the  eyeball,  which  occurred 
during  an  operation  in  which  a  polypoid  growth  was  being 
removed  from  the  nose.     The  patient  being  told  to  clear  the  nos- 


470  AFFECTIONS    OF    THE    EYEBROWS    AND    EYELIDS. 

trils  the  violent  expiratory  effort  forced  the  air  through  the  nasal 
lachrymal  canal  into  the  lids  of  the  right  eye  and  tissues  about 
the  bulb.  The  sudden  closure  of  the  eye,  and  the  enormous  dis- 
tention of  the  lids,  which  prevented  them  from  opening,  equally 
surprised  both  patient  and  surgeon. 

Some  difficulty  has  been  met  in  distinguishing  this  infiltra- 
tion of  air  from  that  in  which  the  content  is  blood.  The  diag- 
nosis can  readily  be  made  if  one  attends  to  the  different  origins 
of  the  two:  emphysematous  swelling  appears  instantly  as  the 
result  of  a  violent  effort  through  the  nose,  and  the  swollen  part 
is  pale,  and  resonant  on  slight  digital  percussion  or  filliping  with 
the  finger;  effusion  of  blood  occurs  more  tardily,  the  skin  is 
lividly  discolored  and  yields  no  resonance  on  percussion.  In 
case  of  emphysema,  if  the  part  be  pressed  on,  the  displacement 
of  the  air  in  the  areolar  spaces  of  the  tissue  reveals  itself  by  a 
sensible  crepitation,  in  most  cases. 

Emphj'sema  of  the  lids  will  disappear  in  a  few  days  through 
spontaneous  absorption.  In  the  case  which  the  author  saw, 
the  swollen  parts  were  punctured,  and  the  most  of  the  air  was 
forced  out  through  the  openings  made.  A  very  important  tiling 
is  that,  for  some  days,  the  patient  should  make  no  strong  expira- 
tory effoio  through  the  nose,  lest  air  again  be  forced  into  the 
palpebral  tissues. 


CHAPTER    XIII. 


DISEASES    OP    THE    EYELID. 


Hordeolum,  Acne  Ciliaris  or  Sty. — Ciliary  acne,  or  sty,  as  it  is 
commonly  named  in  English,  is  an  inflammation  of  the  matrix 
or  follicle  in  which  is  imbedded  an  eyelash.  It  occurs  oftener 
in  the  upper  lid.  It  may  be  single  or  multiple.  It  begins  as  a 
slight  swelling  on  the  border  of  the  lid,  accompanied  by  slight 
itching  and  discomfort  at  the  point.  The  conjunctiva  covering 
and  adjacent  to  the  affected  part  is  intensely  red.  The  tumor 
reaching  the  dimensions  of  a  small  wheat  or  barley  grain  (whence 
its  name),  becomes  filled  with  tenacious  pus.  Ciliary  acne  is 
oftenest  seen  in  the  young  scrofulous  subject.  In  such  person 
the  disease  often  recurs,  and  is  often  concurrent  with  conjunctival 
and  corneal  disease.  Besides  the  local  inconvenience  of  the  dis- 
ease, it  menaces,  by  its  frec[uent  recurrence,  the  ultimate  destruc- 
tion of  the  ciliary  matrix,  and,  consequently,  the  loss  of  some 
of  the  eyelashes,  and  a  permanent  deformity  of  the  lid.  Its 
causation  is  probably  referable  to  a  microphyte. 

Treatmerit. — The  first  thing  to  be  done  is  the  removal  of  the 
eyelash  which  is  lodged  in  the  diseased  follicle;  the  tenacious 
pus  should  be  scooped  out  with  a  small  curette,  and  the  edge  of 
the  lid  smeared  with  the  following  ointment: — 

1^.     01.  Jecoris  Aselli gss 

Ung.  Hydr.  Nitratis 3ss 

Misce. 

This  ointment  may  be  smeared  on  the  outside  of  the  eyelids, 
near  the  roots  of  the  eyelashes,  as  the  patient  is  going  to  bed. 

It  must  be  borne  in  mind  that  constitutional  remedies  should 
be  given;  as  such  the  following  maybe  resorted  to:  bark,  iron, 
and  arsenic,  also  sea-bathing  has  proved  beneficial. 

Chalazion,  otherwise  known  as  tarsal,  gelatinous,  or  fibrinous 
Tumor  of  the  Eyelid. — The  chalazion  is  a  small,  flatly  rounded 
tumor  imbedded  in  the  eyelid,  and  usually  lies  nearer  the  con- 
junctival than   the   dermal   surface.     It   occurs   oftener    in  the 

(471) 


472  DISEASES    OF    THE    EYELID. 

upper  than  in  the  lower  lid,  and  is  situated  about  midway 
between  the  free  and  the  attached  border  of  the  lid. 

This  tumor  may  develop  more  towards  the  inner  or  tlie  outer 
surface  of  the  lid;  in  the  former  case  there  will  be  found  a  slight 
prominence  on  the  outside  when  the  lid  is  lifted  or  everted  from 
the  bulb;  but  if  the  tumor  develop  chiefly  outwards,  a  small 
rounded  prominence  will  appear  in  the  skin.  There  may  coexist 
two  or  more  chalazia  contiguous  or  near  each  other.  Tlie  growth 
is  usually  painless,  yet  if  it  presses  against  and  forces  the  con- 
junctiva inwards,  the  latter  will  become  inflamed,  and  is  the 
site  of  an  itching  sensation. 

Pathologists  usually  refer  the  origin  of  this  tumor  to  a  degen- 
eration of  the  Meibomian  gland;  others  find  the  causation  in  a 
degeneration  of  an  isolated  portion  of  the  tarsal  cartilage.  It  is 
probable  that  the  affection  starts  in  a  Meibomian  gland,  and 
thence  attacks  the  tarsal  cartilage,  in  which  the  gland  is  lodged. 
The  development  is  slow,  and  the  course  of  the  tumor  may 
extend  through  a  period  of  many  months.  When  opened,  a 
cor  tent  of  heterogeneous  material  is  found:  pus  cells,  red  gelat- 
inous matter,  partly  degenerated  and  partly  calcified  material. 
If  the  suppurative  elements  predominate,  and  the  tumor  press 
chiefly  against  the  conjunctiva,  the  latter  sometimes  acutely 
inflames,  and  opens,  and  permits  the  liquid  content  to  escape; 
and  in  this  event,  after  the  rupture  of  the  inner  wall,  there  pro- 
trudes a  small  mass  of  fungous  tissue.  Though  much  of  the 
content  thus  escapes,  nevertheless  healing  is  very  tedious;  the 
spongy  extruded  tissue  will  remain  for  a  long  time  without  much 
change  of  volume,  and  by  its  presence  there  is  caused  some  irri- 
tation of  the  bulb.  Instead  of  thus  rupturing,  the  chalazion  may 
be  the  subject  of  regressive  change,  in  which  the  softened  tissue 
is  lessened  by  atrophy  and  absorption,  so  that  there  finally 
remains  a  dry  calcified  concrement;  and  this  simulates  the  ver- 
itable hailstone,  from  which  this  tumor  has  taken  name.  This 
encysted  concretion  may  remain  indefinitely  without  change  or 
causing  functional  disturbance. 

Treatment. — The  chalazion,  when  it  has  assumed  the  calcified 
form,  need  not  be  interfered  with,  unless  its  volume  is  such  as 
to  make  it  a  conspicuous  deformity;  in  such  a  case  the  hardened 
material  may  be  extracted  through  an  incision  in  the  conjunc- 
tival surface,  done  when  the  lid  is  everted. 

But  if  the  tumor  has  not  reached  the  concrete  or  cretaceous 
form,  its  removal  is  indicated;  and  this  should  be  done  from  the 


PALPEBRAL    DEFORMITIES.  473 

inner  side.  The  lid  must  first  be  everted,  so  as  to  fully  expose 
the  site  of  the  growth.  The  bright  redness  of  the  conjunctiva 
over  the  tumor  will  indicate  the  volume  and  limits  of  the  latter. 
A  dimpled  point  often  corresponds  to  the  central  part  of  the 
growth.  A  tenaculum  must  be  made  to  trans];)ierce  the  inner 
wall  of  the  tumor,  and  a  circumscribing  incision  be  made  around 
the  tumor.  Thus  an  oval  section  of  the  conjunctiva  and  tarsal 
cartilage  is  excised.  With  a  small  curette,  or  Daviel  spoon,  the 
remaining  gelatinous  or  granulative  material  is  to  be  carefully 
removed,  and  the  wall  adjacent  should  be  well  plied  with  the 
instrument,  so  that  a  thin  stratum  of  the  wall  may  be  removed. 
For  if  this  precaution  is  neglected,  there  will  be  a  recurrence  of 
the  tumor  after  a  few  months.  The  treatment,  as  just  described, 
is  the  same  should  there  coexist  two  or  more  chalazia.  Also,  in 
case  tlie  growth  has  opened,  and  a  pouting  mass  of  soft  tissue 
protrudes,  the  remaining  structure  should  be  excised,  for,  if  left 
remaining,  it  would  only  tardily  heal,  to  reopen  again  sooner  or 
later.  In  case  the  tumor  has  developed  more  outwards,  and  is  so 
adherent  to  the  skin  that  it  is  difficult  to  wholly  remove  it  from 
the  inside,  then  it  can  be  done  from  the  outside,  through  inci- 
sion or  excision,  done  parallel  with  the  orbicular  muscle ;  such 
external  cut  should  lie  in  the  fold  which  normally  lies  in  the 
outside  of  the  lid;  thus  done,  the  scar  will  afterwards  be  invisible, 
or,  at  most,  insignificant. 

Palpebral  Deformities. — There  are  several  varieties  of  deformity 
which  are  met  with  in  the  lids,  and  these,  in  the  main,  are  redu- 
cible to  two  classes.  In  the  first  class  the  deformity  arises  from 
too  great  breadth,  or  narrowness  of  the  jDalpebral  slit;  and  in  the 
second  it  consists  of  an  inversion  or  an  eversion  of  the  lid.  Also, 
deformities  of  each  class  may  coexist. 

From  excessive  breadth  of  the  palj^ebral  slit  the  condition  is 
named  lagophthalmos,  or  hare's  eye;  in  this  too  large  a  surface 
of  the  bulb  is  exposed.  This  stare  usually  depends  on  some 
functional  aberration  of  the  muscularity  of  the  lids,  or  it  may 
depend  on  a  swelling,  tumor  or  abscess  of  the  structures  adjacent 
to  the  bulb  of  the  eye.  Protrusion  of  the  bulb  is  sometimes  an 
attendant  on  goitrous  tumor;  and  vivisective  research  here  finds 
the  causation  to  be  an  irritation  of  the  cervical  sympathetic  gan- 
glia which  supply  innervation  to  the  non-striated  muscularity  of 
the  eyelids. 

Treatment. — When  the    stare   is   from   intra-orbital    swelling 
tumor  or  abscess,  this  cause  must  be  sought  for,  and  treated  as 
81 


474  DISEASES    OF    THE    EYELID. 

the  conditions  indicate;  pus  should  be  evacuated  through  ihc  must 
dependent  route,  and  a  growth  removed,  if  possible,  without  lesion 
of  the  bulb. 

But  if  the  exposure  of  the  bulb  does  not  arise  from  the  causes 
just  cited,  but  is  dependent  on  imperfect  closure  of  the  lids,  then 
some  relief  may  be  gotten  by  shortening  the  slit  at  the  outer 
angle.  This  operation  was  originated  by  Walther,  and  consists 
in  removing  at  the  outer  canthus  a  small  section  from  the  upper 
and  lower  lid.  The  part  excised  should  be  from  one-fifth  to  one- 
fourth  of  an  inch  long,  and  should  be  from  half  a  line  to  a  line 
in  depth.  Care  must  bo  taken  to  remove  the  bulbs  of  the  eye- 
lashes. The  opposite  raw  margins  are  to  be  brought  and 
retained  in  union  by  two  or  three  sutures;  and  over  the  wound 
isinglass  plaster  and  an  occlusive  bandage  should  be  placed. 
After  this  procedure,  the  outer  commissure  may  be  drawn 
upwards  in  the  movements  of  the  bulb,  and  give  an  upward 
aspect  to  the  eye;  to  counteract  this,  Graefe  has  proposed  to  excise 
a  small  triangle  from  the  integument  beyond  the  angle,  accord- 
ing to  a  plan  practiced  by  Dieffenbach.  To  do  this,  trim  only 
the  border  of  the  lower  lid,  then  excise  from  the  temporal  skin 
near  by  a  triangular  portion  of  skin.  The  base  of  this  inverted 
triangle  should  be  a  continuation  of  the  commissure,  and  the 
apex  should  look  downwards  towards  the  outer  i:»art  of  the 
cheek.  The  freshened  border  of  the  lower  lid  is  next  drawn 
outwards  and  attached  to  the  base  of  the  triangle  by  sutures. 
The  result  of  this  work  will  be  to  draw  the  lower  lid  outwards, 
and  to  uplift  it,  so  the  palpebral  slit  wall  be  lessened  in  its 
surface.     The  wounds  made  must  be  closed  by  fine  wire  suture. 

Should  tlie  lagophtbalmos  depend  on  a  goitrous  tumor,  this 
should  be  removed.  The  writer's  experience  inclines  him  to 
think  that  protrusion  of  the  bnlb  arises  oftener  from  the  paren- 
chymatous than  from  the  cystic  form  of  goitre;  the  solid  struc- 
ture of  the  latter  causes  more  disturbance  of  the  innervation  of 
the  eye. 

From  palsy  of  the  lower  lid,  the  lower  portion  of  the  bulb 
may  be  exposed ;  likewise,  the  tears  may  not  be  carried  towards 
the  inner  angle,  but  they  escape  over  the  lid  upon  the  cheek. 
The  abnormally  exposed  portion  of  the  bulb  becomes  irritated, 
and  the  conjunctival  vessels  become  congested,  and  give  the  eye 
an  unsightly  appearance.  In  such  cases  a  canthoplastic  opera- 
tion may  be  performed,  in  which  the  commissural  borders  of  the 
lids  are  pared  and  united  by  suture.     Or,  in  place  of  this,  the  gap- 


ANKYLOBLEPHARON.  475 

ing  commissure  may  be  closed  by  a  strip  of  adhesive  plaster 
fixed  to  the  pendent  lid,  and  fastened  in  a  vertical  or  oblique 
direction.  In  this  way  the  writer  has  known  a  patient  to  satis- 
factorily correct  the  faulty  position  of  his  drooping  eyelid. 

Ankyloblepharon,  Blepharophimosi^^,  or  Narrowness  of  the  Palpe- 
bral Opening. — Blepharophimosis  may  occur  congenitally  as  the 
result  of  a  defective  separation  of  the  lids  in  the  embryo;  it  may^ 
as  an  anthropological  characteristic,  be  the  normal  disposition  of 
the  eyelids.  In  the  Japanese  and  Chinese  it  is  seen,  and  when 
exaggerated  it  becomes  a  striking  feature  indicative  of  the  Mon- 
golian race. 

It  is  frequently  acquired,  and  the  cause  then  is  to  be  found  in 
some  antecedent  inflammatory  condition;  or  it  can  arise  from  a 
permanent  spasmodic  state  of  the  orbicular  muscle.  The  most 
common  cause  is  an  inflammatory  or  ulcerative  condition  of  the 
lids,  especially  of  the  outer  commissure,  terminating  in  adhesion 
of  the  raw  surface,  and  a  consequent  lessening  of  the  space 
between  the  lids.  Also  a  wound,  especially  that  produced  by  a 
burn  in  the  adjacent  temporal  region,  may,  in  tlie  process  of 
cicatrization,  cause  outward  traction  of  the  commissure,  and  thus 
produce  narrowness  of  the  palpebral  slit.  A  lupoid  ulcer  on  the 
temple  may  act  thus. 

Blejoharophimosis  is  often  complicated  with  adherence  of  the 
lids  to  the  bulb,  and  this  complication  renders  successful  treat- 
ment much  more  difiicuh. 

The  narrowness  of  the  palpebral  slit,  besides  being  a  con- 
spicuous deformity,  may,  when  extensive,  disturb  the  jjatient  by 
contracting  the  field  of  vision.  Thus,  when  tlie  eye  is  rolled 
upwards,  the  upper  lid  may  shut  oif  a  part  or  the  entirety  of  the 
visual  field,  and  similar  interference  may  be  caused  by  the  lower 
lid. 

Treatment. — AVhen  the  closure  depends  on  cicatricial  adhesion, 
the  treatment  will  vary  according  to  the  character  and  extent  of 
the  coalescence.  Fractional  marginal  adhesion  is  overcome  by 
simply  severing  the  united  bands,  and  subsequent  frequent  move- 
ment of  the  lids.  At  night  the  patient  must  occasionally  be 
awakened,  otherwise  the  closed  lids  would  soon  cohere  again. 

But  a  diff'erent  treatment  is  demanded  where  the  narrowing 
depends  on  complete  closure  of  the  outer  commissure;  mere  sep- 
aration of  the  united  borders  would  be  followed  by  reunion;  to 
prevent  this,  several  plastic  procedures  have  been  resorted  to. 
The  aim  in  this  work  is  to  cover  the  wounded  borders  with  a 


470  DISEASES    OF    THK    EYELID. 

coating  of  skin  or  mucous  membrane.  The  simplest  plan  is  that 
of  Yon  Amnion  and  Uicliet,  wliich  is  as  follows:  The  closed  angle 
is  to  be  slit  outwards;  and  this  may  be  done  with  a  bistoury,  or 
a  pair  of  scissors,  the  incision  being  carried  horizontally  outwards 
the  distance  of  a  fourth  or  third  of  an  inch;  and  this  cut  must 
include  the  entire  thickness  of  the  skin  to  the  conjunctiva.  The 
cut  should  be  straight.  Some  bleeding  will  ensue,  which,  however, 
if  it  does  not  spontaneously  cease,  can  be  controlled  by  torsion. 
The  adjacent  conjunctival  membrane  is  now  to  be  dissected  up, 
and  attached  by  suture  to  the  elongated  connnissure,  so  as  to  give 
to  each  raw  edge  a  mucous  coating,  which  will  not  permit  reunion 
of  the  wounded  surfaces.  It  is  well  to  preliminarih'-  detach  for 
some  minutes  the  conjunctiva  which  is  to  be  used  for  covering 
the  wound,  and  thus  permit  it  to  retract  as  much  as  it  tends  to 
do,  before  it  is  transplanted  to  the  surface  which  it  is  destined  to 
cover;  thus  excessive  tension  will  be  avoided.  The  sutures 
should  be  removed  in  about  forty-eight  hours.  The  result  of 
this  operation  is  fairly  satisfactory;  however,  it  often  occurs  that 
there  remains  some  impediment  to  the  inward  motion  of  the 
bulb;  in  such  movement  the  conjunctiva  is  lifted  at  the  outer 
commissure  into  a  slight  ridge.  In  the  operation  described,  Yon 
Ammon  pulled  the  conjunctiva  outwards,  and  attached  it  directly 
to  the  divided  derm.  Richet  split  the  conjunctiva,  and  then 
turned  one  part  upwards  and  the  other  downwards,  attaching 
each  by  sutures  to  its  adjacent  border.  Instead  of  lining  the 
wounded  border  with  conjunctiva,  Cusco  inverts  the  skin,  which 
has  been  loosened  somewhat  from  the  incised  border,  and  attaches 
this  to  the  conjunctiva  by  sutures.  The  last  mode  has  the  objec- 
tion that  it  creates  some  deformity  of  surface.  In  whatever  way 
the  commissure  is  elongated,  for  a  few  days  the  eye  should  be 
closed,  and  a  compress  wet  with  water  must  be  retained  uoon 
the  wound. 

SymUcpharon  or  Bulbo-palpehral  Union. — In  this  condition  of 
the  e^^e,  the  lid  is  adherent  to  the  globe,  and  that  adherence  may 
be  partial  or  complete.  Partial  adhesion  may  affect  one  lid  alone, 
or  both  may  be  implicated.  Such  limited  symblepharon  maybe 
direct  in  which  the  lid  coheres  to  the  bulb,  or  the  connection  may 
be  through  the  medium  of  a  longer  or  shorter  band.  The  jiros- 
pect  of  treatment  being  successful  is  much  greater  when  the 
adliesion  is  by  a  band;  but  when  the  adhesion  is  immediate  and 
of  large  extent,  the  surgeon  meets  a  problem  which  is  extremely 
difficult  of  solution.     Functional  impairment  is  great  when  the 


SYMBLEPHARON.  477 

adhesion  involves  the  most  of  the  conjunctival  covering  of  the 
bulb;  movement  is  then  hampered,  and  the  normal  condition  of 
the  tears  being  disturbed,  they  escape  on  the  cheek. 

Symblepharon  is  often  caused  by  burns;  hot  water,  steam,  or 
molten  metal  coming  in  contact  with  the  conjunctiva  can  cause 
a  burn  from  which  the  mucous  surface  of  the  lid  and  bulb  becom- 
ing ulcerated,  the  parts  cohere.  Lead  and  other  metals  brought 
by  heat  to  fusion,  during  their  use  in  the  mechanical  trades,  by 
careless  handling  or  through  explosive  action,  may  be  thrown 
into  the  eye  and  lodge  beneath  the  lids.  Such  lesion  often  leads 
to  adhesion  of  the  lid  to  the  bulb.  Again,  a  chronic  inflammation 
arising  from  trachomatous  affection  may  finally  end  in  partial 
or  complete  obliteration  of  the  space  between  the  lids  and  the 
bulb. 

Treatment. — When  the  adhesion  is  limited,  and  indirect,  by 
means  of  a  band,  the  treatment  consists  in  severing  this  band 
close  to  the  bulb,  and  also  close  to  the  lid,  and  then  closing  each 
conjunctival  wound  by  fine  suture.  These  sutures  should  remain 
in  place  until  the  wounds  are  securely  closed.  Again,  if  the 
adhesion  is  direct,  and  limited,  the  lid  should  be  dissected  from 
the  bulb,  and  then  the  two  wounds  closed  in  the  manner  just 
described. 

In  case  the  symblepharon  is  on  a  large  scale,  and  either  or 
both  lids  are  directly  adherent  to  the  globe,  then  the  operator  is 
confronted  with  a  task  which  has  awakened  the  best  efforts  of 
surgical  invention.  The  object  sought  for  is,  after  separation  of 
the  parts,  to  obtain  a  covering  for  one  or  both  of  the  surfaces 
which  will  not  readhere. 

The  earliest  recorded  method  of  operating  was  that  of  Fabri- 
cius,  who,  two  and  a  half  centuries  ago,  sought  to  maintain  the 
separation  of  the  parts  by  means  of  cicatricial  tissue.  This  idea 
was  more  recently  pursued  by  Himly,  who  proceeded  as  follows: 
A  leaden  thread  was  introduced  through  the  connecting  material 
at  its  deepest  portion,  corresponding  to  the  site  of  the  transition 
fold  of  the  normal  eye,  that  is,  the  bottom  of  the  pocket  formed 
by  the  palpebral  and  bulbar  conjunctiva.  This  thread  of  lead  is 
left  in  site  until  the  pierced  parts  cicatrize  around  it.  After  an 
opening  has  been  established,  surrounded  by  scar-tissue,  the 
remainder  of  the  connecting  structure  is  divided.  The  results  of 
this  method  were  such  as  to  encourage  the  endeavor  to  find  a 
better  one.  ■ 

Arlt,  Teale,  Knapp   and   others   have   each  announced  and 


478  DISEASES  OF   THE   EYELID. 

published  ways  in  which  they  have  been  successful  in  obtaining 
separation.  If  the  condition  of  tlio  eye  is  such  as  to  permit  the 
transplantation  of  a  conjunctival  flap  into  tlie  bottom  of  the  cul- 
de-sac  formed  by  the  separation  of  the  lid,  then  a  successful  result 
can  thus  be  obtained.  Such  shifted  conjunctiva  should  be  taken 
from  the  bulb  and  have  its  pedicle,  for  vascular  maintenance,  near 
the  bottom  of  the  new-made  cul-de-sac;  this  flap  is  to  be  fastened 
by  small  sutures.  After  this  implantation  the  remainder  of  the 
opposite  raw  surfaces  must  be  kept  asunder  by  means  of  gutta- 
percha tissue;  and  in  the  absence  of  this,  the  silk  tissue  might  be 
interposed.  Instead  of  the  mucous  tissue  of  the  conjunctiva, 
should  it  be  impossible  to  obtain  the  latter,  a  slip  of  dermal  tissue 
from  the  lid  or  adjacent  check  .might  be  carried  through  a  slit 
made  in  the  lid,  and  implanted  in  the  bottom  of  the  space  formed 
between  the  bulb  and  lid.  Tlie  operative  i)rinciple  involved  in 
these  methods  is  that  where  synechial  adhesion  exists  between 
parts,  whether  of  congenital  or  accidental  origin,  the  surgeon,  if 
he  hopes  to  obtain  permanent  separation,  must  cover  the  bottom 
of  the  angle  of  divergence,  which  the  opposite  surfaces  form,  with 
non-adherent  tissue,  viz.,  cicatricial,  mucous  or  dermal.  This  is 
the  principle  involved  in  the  relief  of  palpebral  adhesion,  the 
webbed  finger,  or  the  narrowed  openings  into  the  alimentary  eanal. 
And,  if  possible,  kindred  tissue  should  rejJace  kindred  tissue,  viz., 
derm  should  replace  derm,  and  mucous  membrane  replace  mucous 
membrane. 

The  skin-graft,  introduced  by  Reverdin  as  an  aid  in  closing 
raw  or  granulating  surfaces,  has  found  more  extensive  use  than 
its  author  foresaw.  Conjunctival  grafting  has  been  resorted  to 
for  relief  in  pal})ebral  adhesion;  and  for  tliis  purpose,  the  con- 
junctiva of  tlie  rabbit  and  dog  has  been  transplanted  to  man's 
eye.  Thus  AVolfe  and  De  Wecker  report  successful  operations. 
The  mucous  membrane  of  man  has  been  used,  viz.,  that  from  the 
mouth  of  the  patient  has  been  transferred  to  his  eye  to  replace 
deficient  conjunctiva.  "Where  this  transplantation  has  been  done, 
it  has  been  noted  that  the  transplanted  grafts  were  absorbed  after 
they  had  served  the  end  of  separating  the  parts. 

Ectropion. — Ectropion  implies  aversion  or  turning  outwards; 
and  this  condition  is  not  unfrequently  seen  in  the  eyelid.  It 
occurs  in  the  upper  and  lower  lid ;  yet  oftener  in  the  lower  one. 

The  most  common  cause  of  palpebral  eversion  is  a  wound  of 
the  surface  of  the  lid,  as  from  a  burn,  or  some  affection  which 
induces  ulceration  of  the  outer  face  of  the  lid.     Also  a  wound  of 


ECTEOPIOX.  479 

the  adjacent  surface,  which  in  liealing  cicatrizes,  contracts,  and, 
pulhng  on  the  skin  of  the  lid,  displaces  the  free  border  of  tlie  lid 
outwards;  that  is,  the  free  border  is  drawn  towards  the  attached 
one  and  the  lid  is  everted.  Thus  a  burn  on  the  lid,  or  on  the 
skin  around  the  eye,  may  act.  Affection  of  the  bony  wall  which 
surrounds  the  eye  may  end  in  inflection  of  surface,  and  become 
the  cause  of  one  of  the  most  obstinate  forms  of  palpebral  eversion. 
"Where  the  cause  of  ectropion  is  a  scar,  it  will  be  more  complete  in 
proportion  as  the  cicatrix  lies  at  right  angles  to  the  long  axis  of 
the  lid;  and  it  is  greatest  in  such  case,  if  one  end  of  tlie  scar  is 
attached  to  an  adjacent  bone. 

There  is  a  troublesome  species  of  ectropion  in  which  the  derm 
of  the  lid  is  the  site  of  no  disease  or  change,  but  the  eversion  is 
produced  by  a  reflex  irritation  originating  in  a  diseased  condition 
of  tlie  cornea  and  bulbar  conjunctiva;  in  the  effort  to  close  the 
eye  to  exclude  light,  the  orbicular  muscle  is  violently  contracted 
so  as  to  force  the  conjunctiva  forwards,  and  cause  it  to  be  caught 
between  the  lids,  where  it  appears  as  a  mass  of  red  swollen  tissue, 
similar  to  what  is  presented  by  the  mucous  membrane  in  prepu- 
tial paraphimosis.  The  spasmodic  ectropion,  as  is  evident,  differs 
widely  from  that  of  cicatricial  origin;  the  former  will  disappear 
under  appropriate  treatment  of  the  disease  of  the  eyeball,  whicli 
is  the  prime  cause,  while  that  caused  by  a  scar  is  only  removed 
by  some  surgical  procedure. 

An  accompaniment  of  eversion  from  cicatricial  cause  in  its 
w^orst  form,  is  an  elongation  of  the  free  border  of  the  lid.  Cica- 
tricial ectropion  is  slow  in  its  development,  since  it  is  only  after 
a  long  lapse  of  time  that  scar  tissue  reaches  its  final  point  of 
contraction;  and  this  precautionary  fact  must  be  remembered  in 
the  selection  of  the  time  for  operating,  for  the  work  should  be 
delayed  until  the  vascular  tissue  has  become  transformed  into 
fibrous  structure. 

Two  indications  are  present  in  palpebral  eversion;  first,  to 
cover  the  exposed  bulb  and  thus  protect  the  latter  against  irrita- 
ting agencies;  and,  secondly,  diffusion  of  the  tears  over  the  front 
of  the  eyeball,  and  their  conduction  away  by  the  natural  channels 
of  escape.  The  procedure  to  be  adopted  will  vary  greatly,  accord- 
ing to  the  grade  of  the  eversion.  As  a  rule,  the  lower  lid  is  the 
one  which  oftener  requires  correction.  The  operations  may  be 
classified  as  those  done  on  the  lid,  and  those  done  on  the  surface 
adjacent  to  the  eye,  or  a  combination  of  the  two.  Some  plastic 
device  involving  transplantation  or  shifting  of  tissue  is  often 
required. 


480 


DISEASES  OF   THE   EYELID, 


A  method  in  vogue  among  French  surgeons  is  to  unite  tlie 
two  lids  directly  or  indirectly.  Tarsorrhaphy  may  be  done 
directly  by  trimming  the  opposite  edges  of  the  lids  and  then 
uniting  these  by  suture;  and  such  sutural  union  maybe  limited, 
or  done  to  such  an  extent  as  to  -wholly  close  the  eye.  A  serious 
objection  to  this  method  is  that  in  trimming  the  lids  the  follicles 
of  the  eyelashes  may  be  injured,  so  that  when  the  patient  is  cured 
he  is  left  with  a  deformity.  To  avoid  this,  Mirault  has  proposed 
to  close  the  eye  by  lifting  a  V-shaped  flap  from  one  lid,  and, 
having  made  a  vertical  incision  on  the  opposite  orbital  border,  to 
implant  the  apex  of  the  V  in  this  cut,  so  that  when  it  has  healed 
in  the  new  position,  it  will  maintain  closure  of  the  lids.  This 
triangular  flap  is  so  disposed  that  its  dermal  face  is  turned  towards 
the  dermal  face  of  tlie  lid  across  which  it  is  carried.  This  way 
of  closing  by  means  of  a  dermal  bridge,  or  that  in  which  the 
borders  are  directly  sutured,  to  be  effective,  must  be  continued  for 
several  months.  Ectropion  is  not  always  cured  in  the  manner 
here  described;  for  after  the  liberation  of  the  lids,  eversion  some- 
times recurs. 

To  rectify  ectropion,  Graefe  advises  the  following  method: 
An  incision  is  to  be  made  along  the  border  of  the  everted  lid 


Figure  62.    Showinsf  Dieffenbach's  Figure   63.    Showing    Von   Am- 

method  of  operating  for  the  relief  of  mon's  plan  of  operating  in  ectro- 
palpebral  eversion.  pion. 

from  the  outer  commissure  to  near  the  punctum  lachrymale;  by 
this  cut  the  free  border  is  split  into  an  inner  and  an  outer  stratum. 
A  crescentic  flap  is  next  to  be  formed  by  cutting  through  the 
dermal  layer  o*f  the  lid;  this  flap,  which  is  convex  towards  the 
attached  border  of  the  lid,  is  to  be  so  detached  from  the  subjacent 
structure  of  the  lid  that  the  eversion  of  the  latter  can  be  corrected, 
when  the  flap  is  to  be  fixed  in  its  rectified  site  by  sutures. 

Palpebral   eversion    is   corrected   by   Dieffenbach    and   Yon 
Amnion,   by   o})erations    resembling   each   other.       Dieffenbach 


ECTROPION. 


481 


excised  a  portion  of  the  commissural  border  of  the  lid  which  is 
everted;  then  an  equilateral  triangle,  with  apex  downwards  and 
base  continuous  with  the  commissure,  is  excised  from  the  temple 
adjacent.  The  sides  of  this  triangle  should  not  exceed  one-third 
of  an  inch.  The  trimmed  border  is  next  drawn  outwards  and 
sutured  to  the  base  of  the  triangle;  thus  the  lid  is  rectified  by 
lateral  sliding.     This  method  is  shown  in  Figure  62. 

Von  Amnion's  plan  is  to  excise  an  elongated  isosceles  triangle, 
of  which  the  narrow  base  rests  against  the  bulb  within  the  com- 
missure, as  shown  in  Figure  63.  The  sutural  closure  of  this 
triangle  will  bring  the  everted  lid  or  lids  into  normal  place.  The 
twisted  or  hair-lip  suture  may  be  resorted  to  with  advantage  to 
close  and  immobilize  the  parts.  These  two  methods  just 
described,  tend  to  shorten  the  border  of  the  lid,  which  is  too 
long,  as  has  before  been  remarked;  this  is  specially  so  in  Dieffen- 
bach's  plan,  in  which  the  outer  portion  of  the  border  is  excised. 


Figure  64.     Elucidating    Szyma-  Figure  65.     Showing  sutural  line 

nowskj^'s  method  of    operating    for        that   remains   after   Szymanowsky's 
relief  of  entropion.  operation. 

An  operation  cognate  to  those  just  described  is  that  of  Szyma- 
nowsky.  This  consists,  as  shown  in  figure  64,  in  the  excision  of  a 
triangular  portion  of  derm  from  the  temporal  region,  adjacent  to 
the  commissure.  Two  sides  of  the  excision  start  and  diverge 
outwards  from  the  commissure;  these  divergent  lines  include  a 
small  section  of  each  lid,  and  are  to  be  sutured  to  the  third 
or  temporal  line.  The  sutural  closure,  shown  in  Figure  65,  has 
had  the  effect  of  restoring  the  everted  lids  to  normal  position. 

As  before  mentioned,  tarsorrhaphy  is  much  practiced  by  the 
French  surgeons;  and  the  work  is  done  by  trimming  each  free 
border  so  that,  united  by  sutures,  they  will  unite.  The  inner 
edge  of  the  free  border  is  trimmed  off,  care  being  taken  to  spare 


482 


DISEASES    OF    THE    EYELID. 


the  bulbs  of  the  eyelashes.  The  outlets  of  the  Meibomian  glands 
must  necessarily  be  interfered  with  in  this  work;  yet  their  closure 
does  not  seem  to  be  followed  by  such  trouble  as  might  be  aj)prc- 
hended;  no  cyst  by  retention  has  followed  such  occlusion.  Fine 
silken  thread  is  used  for  the  sutures,  which  may  be  removed  after 
three  or  four  days,  when  the  union  will  be  found  quite  complete. 
Along  with  tliis  closure,  some  work  maybe  required  on  the  evert- 
ing cicatricial  structure;  for  example,  the  scar  maybe  divided 
and  become,  by  interstitial  growth,  somewhat  elongated;  also, 
plastic  operations  on  the  lids  are  facilitated  by  this  immobiliza- 
tion. 

The  effort  to  overcome  cicatricial  e version  by  division  of  the 
scar  and  filling  the  wound  with  lint,  was  an  old  method,  which 
theoretically  would  seem  to  promise  much,  but  ])ut  into  practice 
it  has  yielded  so  many  disappointments  that  this  plan  of  treat- 
ment has  been  nearly  abandoned. 

Bonnet  rectified  the  cicatrized  eversion  by  making  a  horizon- 
tal incision  in  the  lid,  as  seen  in  Figure  G6;  then  by  lifting,  if  it 


Figure  66.    Showing  Bonnet's  plan  of  treating  eversion  of  the  eyelid. 

were  the  lower,  or  drawing  down  if  it  were  the  upper  lid,  the 
wound  is  converted  into  a  lozenge-slia])ed  figure;  closure  is  now 
done  while  the  wound  is  thus  shaped  by  liorizontal  sutures.  The 
result  will  be  to  broaden  the  lid. 

T.  Wharton  Jones  rectifies  the  ectropion  by  making,  as 
shown  in  Figure  67,  a  flap,  the  pedicle  of  which  is  directed 
towards  the  free  margin  of  the  lid.  This  triangular  flap  is 
dissected  up  so  that  it  liberates  the  lid,  and,  the  fiajD  being  lifted 
towards  its  attachment,  the  remaining  open  space  is  closed  later- 
ally by  sutures.  Thus  done,  the  closed  space  becomes  a  prop  to 
the  uplifted  fia|) ;  and  the  result  is  lengthening  of  the  vertical  span 
of  the  lid. 

Gudrin's  method,  slio-^n  in  Figure  GS,  is  to  make  an  incision 
in  the  form  of  a  W,  and  dissect  up  the  lateral  angular  flaps;  and, 


ECTKOPION. 


483 


having  forced  these  towards  the  free  border  of  the  hd,  they  are 
united  together  over  the  intervening  angular  point,  which  is  left 
remaining  adherent. 

The  writer  has  employed  in  his  practice  several  of  the  preced- 
ing methods  for  the  relief  of  ectropion ;  yet  the  relief,  wdiich  was 


Figure  67.     Showing  T.  Wharton  Jones'  operation  for  the  relief  of  ectro- 
pion.    Sutural  closure  is  seen  on  the  left  side. 

aimed  at,  was  not  always  realized;  in  fact,  the  result  was  often 
unsatisfactory.  And,  though  at  the  time  of  the  operation  resti- 
tution to  normal  position  was  secured,  yet,  after  healing,  the 
former  mal-position  gradually  reappeared;  the  wounds  made  in 
cicatrizing,  shortened  the  surface,  and  the  previous  deformity  was 
present  again.  The  usual  cause  of  this  is  that  scar  tissue  caused 
by  a  burn,  or  similar  wound,  being  the  constituent  of  the  surface 
which  is  operated  on,  the  elements  of  inevitable  recurrence  are 


Figure  68.    Showing  Guerin's  method  of  operating  for  relief  of  eversion  of 
the  lower  lid.    Sutural  closure  is  seen  on  the  right  side. 

present.  These  circumstances  have  led  the  writer  to  attempt 
rectification  of  the  everted  lower  lid  by  a  plan  differing  from  any 
of  those  before  described.  His  first  operation  was  done  in  1870, 
as  follows,  upon  a  lower  eyelid  everted  by  a  burn:  First  make 
an  incision  through  the  lid  a  half  inch  long  near  its  attached 


484 


DISEASES    OF    THE    EYELID. 


border.  Next  between  tliis  opening  and  the  free  border  a  flap  is 
to  be  uplifted  from  the  conjunctival  side  with  its  pedicle  towards 
the  free  border.  Tliis  flap  should  be  a  half  inch  broad,  and 
should  be  divested  of  its  conjunctival  covering;  that  is,  it  should 
be  raw  on  both  sides.  It  contains  tarsal  cartilage  and  portions 
of  the  divided  Meibomian  glands.  The  free  end  of  this  flap  is  to 
be  drawn  into  the  horizontal  slit  first  made,  and  retained  there 
by  sutures  placed  on  the  outside,  and  traversing  the  derm  of  the 
lid.  The  traction  on  this  flap  and  its  fixation  in  the  cut  tlirough 
the  lid,  will  correct  the  eversion  if  tliis  be  not  very  great;  that  is, 
the  method  is  most  applicable  to  cases  in  which  but  a  })art  of  the 
lid  is  involved.  But  in  cases  in  which  the  correction  cannot  be 
whollv  accomplished  b3'this  plan,  still  it  may  aid  other  accessory 
plastic  work.  The  advantage  of  utilizing  this  intra-palpebral 
flap  is  til  at  it  surely  disposes  of  the  unsightly  mass  of  pouting 
tissues  which  so  disfigures  the  eye,  and  uses  the  same  for  a  sup- 
port of  the  lid.  No  trouble  arises  from  the  divided  and  shifted 
Meibomian  glands.  The  author  has  only  resorted  to  this  method 
for  the  correction  of  eversion  of  the  lower  lid;  it  might,  however, 
be  used  in  the  upper  lid. 

There  is  sometimes  seen  a  deformity  of  the  eye,  in  which  there 
is  a  depression  of  the  outer  angle ;  and  this  is  associated  with 
some  eversion  of  the  lower  lid.  For  relief  in  this  case,  Denon- 
villiers  has  planned  an  ingenious  operation,  shown  in  Figure 
69,  styled  an  exchange  of  flaps.     To  do  this,  make  an  incision 


FiGCRE  69.    Showing  Denonvilliers'  plan  of  elevating  the  outer  angle  of  the 
eye.     Closure  is  shown  on  tlie  right. 

above  and  below  the  eye,  converging  and  meeting  a  few 
lines  beyond  the  outer  commissure.  From  the  inner  end  of  the 
upper  incision, and  from  overthe  middle  of  the  brow,  carr}'^  a  curved 
third  incision  downwards  and  outwards,  ending  on  the  temple. 
Thus  a  flap  is  described,  which  is  uplifted  and  carried  down- 


ECTROPION,  485 

wards  and  sutured  below  tbe  eye.  As  this  is  done,  the  angular 
flap  beyond  the  commissure  is  carried  upwards  and  occupies 
some  of  the  space  left  by  the  upper  flap.  A  small  space  will  be 
left  above  the  brow,  which  may  be  closed  by  stitches,  or  allowed 
,to  cicatrize,  and  draw  the  brow  upwards. 

A  scar  causing  the  eversion  of  the  lid  may  be  of  such  a  char- 
acter that  the  work  of  correction  can  only  be  done  by  excising 
the  cicatrix  and  substituting  in  its  stead  healthy  tissue  borrowed 
from  the  adjacent  surface.  This  plastic  work  will  be  easily  done 
if  the  eyelashes  still  remain;  then  the  operation  (the  steps  of 
which  demand  special  planning  in  each  case)  will,  in  the  main, 
consist  of  excision  of  the  scar  tissue,  and  then,  for  the  upper  lid, 
uplift  a  pedicled  flap  from  the  frontal  or  temporal  region;  or  if 
it  be  the  lower  lid,  form  the  flap  from  the  temporal  or  malar 
derm,  and  then  transpose  and  suture  the  flap  in  its  new  position. 
If  a  portion  of  the  free  border  of  the  lid  be  involved  in  the 
scar,  this  may  be  excised  and  replaced  by  the  transplanted  flap. 
As  the  flap  will  shorten,  it  should  be  longer  than  the  remaining 
border  of  the  lid.  If  considerable  allowance  is  not  made  for 
such  retraction,  the  new-formed  border  will  be  too  short,  as  hap- 
pened in  a  case  operated  on  by  the  writer. 

In  some  cases  in  which  the  scar  is  small,  this  may  be  excised, 
leaving  a  triangular  space,  as  shown  in  Figure  70 ;  the  closure 


c 

Figure  70.     Showing  a  plan  of  DiefFenbach  of  correcting  ectropion. 

may  then  be  effected  according  to  the  plan  of  Dieffenbach,  in 
which  the  incision  a  6  is  extended  to  the  right  and  left,  when  the 
adjacent  derm  a  c  and  &  c  is  to  be  uplifted,  and  the  sides  of  the 
triangle  are  to  be  united  by  suture;  the  efl'ect  will  be  to  force  the 
everted  border  upwards.  Though  in  this  way  the  position  of  the 
lid  can  be  improved,  yet,  as  the  writer  has  found,  some  pouting 
of  the  border  will  remain. 

A  remarkable  operation  for  the  relief  of  cicatricial  ectropion 


486  DISEASES    OF    THE    EYELID. 

was  done  by  Wadswortb,  of  Boston,  in  1876.  After  preparation 
of  tlie  part  to  be  operated  on  by  removal  of  its  surface,  a  flap 
was  taken  from  tlie  arm  and  at  once  transplanted  on  tbe  lid. 
The  flap  thus  transplanted  was  two  and  one-half  inches  long, 
one  and  one-fourth  inches  broad,  and  one-half  inch  thicL 
AVatlsworth  found  that  the  transplanted  piece  contracted  greatly, 
and  he  directs  that  due  allowance  for  tliis  be  made.  Tlie  mate- 
rial was  retained  in  position  by  means  of  gold-beater's  skin  and 
an  overlying  comj)ress.  After  the  lapse  of  four  months,  the 
result  was  satisfactory. 

This  plan  of  Wadswortb  diflers  from  that  of  Thiersch,  who 
covers  raw  or  granulating  surface  by  material  from  the  upper 
structure  of  the  skin,  in  which  only  the  apices  of  the  papillary 
layer  are  included. 

Entropion. — Entropion,  or  inversion  of  the  lid,  has  a  perni- 
cious effect  on  the  eye  through  the  mechanical  action  of  the  free 
borders  of  the  lid  and  the  eyelashes  impinging  against  the  bulb; 
the  eyelashes  are  the  chief  causes  of  the  mischief.  The  general 
causes  of  palpebral  inversion  may  be  classified  under  three 
heads,  viz.,  cicatricial  shortening,  spasm  of  the  lid,  and  lessened 
volume  of  the  eyeball;  the  first  and  second  causal  agencies  fre- 
quently exist  together.  The  upper  lid  is  the  one  oftener  affected. 
Its  superior,  pendent  position,  and  the  larger  tarsal  cartilage  con- 
tained in  the  upper  lid,  give  it  an  advantage  over  the  lower  one, 
where  the  agencies  of  inversion  are  present. 

Cicatricial  inversion  is  seen  in  those  cases  in  which  trachoma- 
tous disease  of  the  inner  surface  of  the  lid  has  continued  until 
the  affected  structure  becomes  changed  to  scar-tissue.  The  har- 
dened points  which  stand  on  the  cicatrized  surface  irritate  the 
bulb,  and,  like  foreign  bodies,  they  produce  spasmodic  closure  of 
the  lids.  Meantime  the  ciliary  portion  of  the  orbicularis  muscle 
hypertrophies  and  contracts  more  violently.  The  continued  irri- 
tation of  the  eyelashes  and  of  the  border  of  the  lid  against  the 
cornea  causes  opacity  of  the  latter,  and  finally  ends  in  almost 
complete  loss  of  sight.  Aside  from  trachomatous  disease,  any 
cause,  which  constantly  irritates  the  eyeball,  may  produce  entro- 
pion through  continued  spasmodic  closure.  In  the  cases  men- 
tioned, especiall}^  in  those  in  which  there  is  trachomatous  cica- 
trization, the  tarsal  cartilage  softens  and  atrophies,  so  that  it  can 
offer  but  slight  resistance  to  the  involution  of  the  border  of  the 
lid. 

Again,  entropion  may  arise  from  lessened  volume  of  the  eye- 


ENTROPION.  487 

ball;  this  may  appear  as  sequel  of  an  inflammation  of  the  eye; 
it  is  not  unfrequeutly  seen  in  the  aged  as  the  effect  of  the  atro- 
phic changes  resulting  from  senility. 

Continued  inversion  of  the  lids  ends  in  producing  corneal 
opacity,  and  a  diversion  of  the  tears  from  their  normal  channel, 
and  the  latter, flowing  on  the  face,  irritate  and  excoriate  tlie  skin; 
to  avoid  these  serious  troubles  surgical  aid  is  sometimes  invoked. 

The  inverted  lid  may  be  attacked  only  on  its  outer  surface, 
or  the  operative  procedure  may  involve  the  entire  thickness  of 
the  Hd. 

Shortening  of  the  outer  surface  and  restoration  ctf  the  lid  to 
normal  position  have  been  attempted  by  cauterization  of  the  outer 
surface;  and  this  can  be  done  by  the  actual  or  potential  cau- 
tery. This  procedure,  which  dates  from  antiquity,  is  most  safely 
done  by  actual  cauterization.  This  is  best  done  with  the  wedge- 
shaped  point  of  the  thermal  cautery,  which  may  be  so  applied  as  to 
make  a  horizontal  eschar  in  the  middle  portion  of  the  lid;  the 
contraction  resulting  from  this  will  correct  the  inversion. 

Instead  of  this  plan,  portions  of  skin  may  be  excised  from 
the  outside  of  the  lid;  this  excision  is  done  by  pinching  up  and 
excising  one  or  more  folds  of  the  skin,  and  then  closing  by 
suture;  or  they  may  be  allowed  to  heal  by  granulation.  These 
excisions  are  commonly  made  horizontally,  yet  one  surgeon  pre- 
fers to. make  them  vertically. 

■The  work  of  correction  may  also  be  made  by  means  of  liga- 
tures passed  through  the  derm  and  tied.  In  this  way  Gaillard 
operated;  his  procedure  consisted  in  passing  threads  vertically 
through  and  underneath  the  derm,  one  near  the  inner  angle  and 
another  near  the  outer  angle;  these  threads  are  to  be  tied  so  as  to 
include  a  section  of  the  skin  as  well  as  the  orbicularis  muscle. 
In  each  ligature  there  is  included  nearly  an  inch  of  vertical  sur- 
face. And  a  third  ligature  may  be  placed  in  the  middle  of  the 
lid,  should  the  inner  and  outer  ones  be  insufficient.  These 
tightly  tied  ligatures  include,  destroy,  cause  cicatrization,  and 
have  the  eff"ect  of  shortening  the  outer  surface  of  the  lid,  and 
thus  eversion  is  efl'ected. 

This  method  of  treating  entropion  by  ligatures  may  be  advan- 
tageously combined  with  Von  Ammon's  operation  of  cantho- 
plasty,  in  which  there  is  excised  an  elongated  triangle  from  the 
derm  at  the  outer  commissure,  as  before  described  in  the  treat- 
ment of  ectropion. 

To  overcome  the  spasm  of  the  orbicularis  muscle,  often  the 


488  DISEASES    OF    THE    EYELID. 

chief  causal  agency  of  entropion,  tlie  muscle  may  be  divided,  or 
a  small  section  of  it  may  be  excised.  The  fibers  of  the  muscle 
nearest  the  free  border  of  the  lid  should  be  attacked;  or  the  divi- 
sion of  the  outer  commissure  may  accomplish  the  same  purpose. 
Others  have  divided  the  orbicularis  muscle  subcutaneously  to 
control  spasm  of  the  latter.  Instead  of  dividing  the  muscle, 
otliers  have  divided  the  internal  palpebral  ligament,  that  is,  they 
have  performed  tenotom3\ 

These  operations  have  been  limited  to  the  dermal  surface  of 
the  lid  or  the  orbicularis  muscle :  that  i.-^,  the  tarsal  cartilage  is 
neglected;  and  since  this  cartilage,  through  alteration  of  form  and 
structure,  often  figures  as  the  chief  cause  of  entropion,  hence  the 
operations  described  often  fail  to  permanently  cure  entropion. 
In  the  worst  cases  the  surgeon  must  attack  the  tarsal  cartilage. 

Sir  Philip  Crampton  was  one  of  the  first  to  include  the  carti- 
lage in  the  operation  for  relief  of  obstinate  cases  of  entropion 
dependent  oa  trachomatous  cicatrization.  His  o^^eration  con- 
sists in  making  two  vertical  incisions  a  half  inch  long,  one  of 
which  is  external  to  the  punctum  lachrymale,  and  the  other  near 
the  outer  angle;  the  incision  traverses  the  tarsal  cartilage,  so  that 
it  becomes  easy  to  evert  the  portion  of  the  lid  between  the  inci- 
sions. Next,  by  means  of  a  species  of  eye  speculum,  he  retained 
the  lid  everted  for  some  days,  until  the  wound  healed.  Reten- 
tion of  the  lid  ill  eversion  is  better  accomplished'  by  Guthrie's 
plan,  who,  after  making  the  vertical  cuts,  excises  a  horizontal 
section  from  the  surface  of  the  outfolded  lid,  and  then  closes  the 
wound  by  suture,  thus  fixing  the  free  border  in  eversion  that 
remained  after  the  wound  had  healed.  During  the  period  of 
healing,  Guthrie  holds  the  lid  in  suspension  b}^  three  ligatures» 
which,  being  passed  through  the  lid  near  the  border,  are  to  be 
fastened  on  the  forehead  or  cheek  by  adhesive  strips.  During 
the  time  of  healing  the  eye  must  be  covered  with  lint  coated 
with  a  bland  ointment,  such  as  simple  cerate  or  spermaceti  oint- 
ment. The  method  of  Crampton,  as  modified  by  Guthrie,  the 
author  has  successfully  emploj^ed  in  the  treatment  of  trachoma- 
tous inversion.  In  one  case  in  which  sight  had  been  nearly  lost 
by  corneal  opacity,  caused  by  friction  of  the  eyelashes  against  the 
bulb,  this  operation  caused  a  restoration  of  average  sight  after  a 
few  months.  In  this  case  the  oblong  dermal  excision  penetrated 
the  tarsal  cartilage. 

Since  the  time  of  Crampton  and  Guthrie,  ophthalmic  surgeons 
in  such  cases  of  obstinate  trachomatous  entropion,  have  sought 


CONGENITAL  DEFORMITY  OF  THE  EYELIDS.  489 

to  correct  the  position  of  the  lid  by  operations  confined  to  the 
cartilage.  Thus  Streatfield  operated  by  making  an  incision  a 
couple  of  lines  from  the  border  through  the  skin  and  muscle  to 
the  cartilage;  and  then  from  the  latter  a  strip  is  to  be  excised; 
and  afterwards,  the  wound  being  sutured,  the  result  is  shortening 
of  the  lid  and  e version  of  its  border.  Wells  operates  somewhat 
similarly,  excising  a  section  of  the  skin,  and  a  wedge-shaped 
strip  from  the  tarsal  cartilage,  with  sutural  closure. 

In  mild  cases  the  operation  of  Anagnostakis  may  be  tried; 
this  consists,  as  will  be  seen  in  Figures  71  and  72,  in  making  an 


-ef-of— 

Figure  71.    Showing  the  triangular  Figure   72.     Showing  the   sutural 

excision  made  by  Anagnostakis  for  line  remaining  after  the  operation  of 
the  relief  of  entropion.  Anagnostakis. 

incision  eight  lines  from  the  free  border,  parallel  with  the  border; 
then  excise  a  triangular  section  of  skin  with  apex  towards  the 
border,  and  base  on  the  first  incision;  dissect  up  the  sides  of  the 
triangle,  and  unite  these  by  suture.  Graefe  operates  similarly,  yet 
makes  his  incision  near  the  free  border,  and  his  excised  triangle 
rests  on  this  cut,  and  has  its  apex  towards  the  brow. 

Congenital  Deformity  of  the  Eyelid. — The  lids  may  be  absent, 
or  nearly  so,  and  then  the  bulb  is  quite  uncovered  in  its  anterior 
section.  A  condition  quite  the  reverse  of  this  may  exist,  viz.,  the 
eye  may  be  closed  by  coherence  of  the  normally  free  borders. 

Treatment. — Where  the  lids  are  absent,  some  plastic  procedure 
might  be  resorted  to;  to  wit,  flaps  from  the  neighboring  frontal, 
temporal  or  facial  derm,  might  be  thrown  over  the  uncovered 
bulb,  and  thus  the  absent  lid  may  be,  in  a  manner,  replaced. 

In  congenital  ankyloblepharon,  if  there  be  no  symblepharon, 
relief  might  be  obtained  by  separating  the  coherent  lids.  If 
the  eyelashes  were  absent,  the  operation  would  be  assured,  if  the 
dermal  and  conjunctival  surfaces  were  united  over  each  border. 

Congenital  coloboma,  or  cleft  of  the  eyelid,  has  been  seen ;  it 
is,  however,  very  rare,  only  a  small  number  of  cases  having  been 
seen.  This  cleft  is  triangular  in  outline,  similar  to  that  in  hare- 
lip, and  in  the  most  of  cases  observed,  the  cleft  was  in  the  upper 
lid,  viz.,  in  ten  of  thirteen  cases  it  was  thus  situated.  In  such 
cases  there  is  a  breach  in  the  tarsal  cartilage,  and  there  are  no 
eyelashes  in  the  gap.  The  affected  lid,  at  the  site  of  opening,  is 
32 


490 


DISEASES   OF   THE   EYELID. 


usually  attached  to  the  adjacent  cornea.  Such  cleft  is  found  in 
the  inner  half  of  the  lid,  near  the  inner  or  greater  angle  of  the 
eye. 

Many  ingenious  theories  have  been  offered  to  explain  the  ori- 
gin of  the  palpebral  cleft;  the  most  satisfactory  explanation  is  that 
it  has  arisen  from  an  arrest  of  development,  during  the  early  period 
of  embryonic  evolution.  This  theory  is  rendered  still  more 
probable  by  the  fact  that  such  cleft  is  often  concurrent  with  other 
congenital  defects:  for  example,  hare-lip,  palatal  or  facial  cleft 
may  exist  with  palpebral  cleft,  in  all  of  whicli  the  primal  cause 
is  iion-closure  of  clefts  or  openings  normally  existing  in  the 
embryo. 

Tiie  treatment  of  congenital  cleft  of  the  eyelid  is  similar  to 
that  of  hare-lip,  provided  the  remaining  portions  of  the  lid  will 
permit  their  closure;  then  the  borders  must  be  pared  and  united 
by  metallic  sutures.  And  should  the  lid  be  adherent  to  the  bulb, 
as  is  commonly  the  case,  this  must  be  detached.  In  the  work  of 
closure,  should  the  existing  portions  of  the  lid  be  so  short  that 
their  closure  would  cause  too  much  tension,  then  subsidiary 
lateral  incisions  must  be  made,  which  will  permit  of  lateral 
sliding. 

EpicantJtus. — There  is  a  rare  deformity  of  the  eye  exliibited 
in  Figure  73  in  which  a  fold  of  skin  of  crescentic  form  lies  over 


Figure  73.    Showing  the  deformity  known  as  epicanthus. 

the  inner  angle;  and  this  circumstance  gave  the  name  of  epi- 
canthus to  the  deformity.     This  cutaneous  fold,  starting  from  the 


BLEPHAROPLASTY,  491 

inner  end  of  the  eyebrow,  passes  downwards  on  the  side  of  the 
root  of  the  nose,  and  then  passes  across  the  angle,  so  as  to  have  a 
semilunar  form  with  concavity  looking  outward.  A  hollow  space 
lies  underneath.  The  effect  of  such  a  fold  which  is  present  in 
the  angle  of  each  eye  is  to  limit  the  field  of  sight  of  one  eye,  when 
vision  is  directed  laterally,  since  the  pupil  is  carried  partly  or 
entirely  under  the  fold.  These  folds  are  movable,  so  that  when 
the  skin  on  the  root  of  the  nose  is  pinched  up  and  folded  on  itself, 
the  defect  is  made  to  vanish,  yet  it  returns  as  soon  as  the  skin  is 
liberated. 

Epicanthus  is  often  associated  with  some  other  ocular  defect; 
there  m.ay  coexist  internal  strabismus,  defective  action  of  the 
upper  lid,  or  smallness  of  the  bulb.  Epicanthus  has  likewise 
been  seen  at  the  outer  angle  of  the  eye;  and  then  it  was  asso- 
ciated with  other  defects  of  the  eye.  The  author  has  seen  a  well- 
developed  case  of  epicanthus  at  the  inner  angle  of  the  eye,  in 
which  there  was  no  other  defect  of  the  eyes.  The  girl's  parents 
did  not  have  the  defect. 

Epicanthus  is  often  seen  in  the  Mongolian  race;  and  in  them, 
as  well  as  in  all  thus  deformed,  the  face  is  broad,  abnormally  flat, 
and  the  nose  is  less  prominent  than  usual.  The  new-born  child, 
in  whom  the  nose  is  normally  without  character  or  shape,  is  often 
accompanied  by  epicanthus  in  which  the  flattened  root  of  the 
nose  slightly  overhangs  the  inner  angle  of  the  eye.  There  may 
be  epicanthus  in  the  congenitally  scrofulous  or  syphilitic  subject. 

Treatment. — Only  in  very  prominent  cases  of  epicanthus  is 
interference  necessary;  should  this  be  demanded,  the  work  is  best 
done  by  removing  a  vertical  section  of  the  derm  on  the  middle 
of  the  nose,  and  then  dressing  by  sutures.  As  this  simple  pro- 
cedure would  probably  leave  the  parts  too  tense,  and  dispose  to 
an  early  reappearance  of  the  deformity,  it  would  be  well  to  guard 
against  tension  by  incising  the  displaced  derm  horizontally,  and 
if  need  be  vertically. 

Blepharoplasty. — The  eyelid  may  be  lost  in  part,  or  in  entirety, 
by  disease,  injury  or  the  surgeon's  knife;  the  operative  work  done 
for  the  purpose  of  repairing  such  loss  is  designated  blepharo- 
plasty. 

Blepharoplasty  may  be  done  in  two  ways:  (1),  by  uplifting  a 
flap  and  turning  this  into  the  defect;  (2),  closure  by  sliding. 

The  flap  procedure  is  known  as  the  method  of  Fricke ; 
in  this  a  flap  is  uplifted  from  the  region  of  the  forehead, 
temple   or  cheek,   and    is   shifted   into   the   defect.      Since  the 


492 


DISEASES    OF    THE    EYELID. 


skin  when  severed  retracts,  tlie  flap  must  exceed  in  every 
direction  the  space  which  it  is  to  occupy;  it  should  be  two 
or  three  times  longer  and  broader  than  the  defect.  The  axis 
of  the  flap  should  make  an  acute  angle  with  that  of  the  defect, 
so  that  torsion  may  be  diminished.  The  margins  of  the  flap 
should  be  cut  perpendicularly,  so  as  to  insure  their  vitality;  and 
its  distal  side  should  be  from  three  to  four  lines  longer  than  the 
nearer  side;  thus  torsion  will  be  rendered  more  easy. 

After  moving  the  flap  into  its  destined  position,  some  sur- 
geons apply  sutures  at  once;  otiiers  use  these  later;  and  all 
counsel  to  attach  the  free  border  of  the  flap  to  the  subjacent  con- 
junctiva. After  the  work  is  done,  the  j)arts  must  be  covered  with 
lint  bearing  some  bland  ointment;  and  both  eyes  should  be 
covered  with  a  compressive  bandage. 

Probably  a  majority  of  the  cases  demanding  these  plastic 
operations  have  arisen  from  excision,  in  which  a  portion  of  the 
lid  has  been  removed,  in  the  extirpation  of  an  epitheliomatous 
affection  of  the  lid.  Such  removal  is  oftcnest  done  at  or  near 
the  commissures.  If  this  be  at  the  inner  angle,  the  lachrymal 
sack  may  be  interfered  with;  and  tlien,  besides  repair  of  surface, 
it  may  be  required  to  remove  the  lachr3'mal  gland.  To  restore 
the  angle  is  no  easy  task.  A  solution  of  the  canthoplastic  prob- 
lem both  at  the  angle  of  the  mouth  and  eyelids  has  often  baffled 


Figure  74.  Illustrating  Hasner's  plan  of  removing  neoplastic  disease  seated 
in  the  eyelids  at  the  inner  angle;  the  appearance  after  sutural  closure  is  shown 
at  the  right. 

or  puzzled  the  adroit  surgical  hand.  A  single  flap  with  an  open 
or  reentrant  angle  may  be  used ;  or  two  flaps  may  be  used.  The 
method  with  two  flaps  is  the  more  usual  one.  Hasner  thus  filled 
a  large  defect  at  the  inner  angle  by  means  of  an   upper  and 


BLEPHAROPLASTY. 


493 


lower  flap,  falciform  in  shape ;  the  beak-like  end  of  one  flap  looks 
outwards,  while  the  other  points  inwards.  These  flaps  form  an 
angle  when  folded  together. 

When  the  defect  is  triangular,  and  beneath  or  above  the  eye, 
and  its  base  occupies  the  greater  part  of  the  border  of  the  lid, 
the  breach  may  be  closed  by  means  of  a  rhomboidal  flap. 
This  is  to  be  formed  on  the  side  of  the  defect:  on  the  temple  for 
the  upper  lid,  and  on  the  cheek  for  the  lower  one.  This  rhom 
boidal  flap  may  be  formed  more  or  less  obliquely,  according  as 
circumstances  demand.  The  wounds  made  can  be  closed  by 
suture. 

The  triangular  defect  below  or  underneath  the  eye  may  also 
be  closed  by  lateral  sliding,  after  subjacent  dissection  of  the 
replacing  derm.  But  as  the  contiguous  surface  will  be  wrinkled 
in  the  act  of  closure,  this  can  be  obviated  by  the  excision  of  a 
triangle,  according  to  Burow's  method.  This  method  has  been 
described  in  the  chapter  on  Plastic  Surgery,  and  is  shown  in 
Figure  75. 


Figure  75.  Illustrating  Burow's  method  of  removing  a  portion  of  the 
lower  eyelid;  also  subsequent  closure  after  excising  a  triangle  from  the  temple; 
the  sutural  closure  of  the  wounds  is  shown  at  the  right. 

In  the  work  of  blepharoplasty  there  has  been  an  attempt 
made  to  transplant  a  flap  with  the  semblance  of  eyelashes. 
This  has  been  done  by  so  incising  a  flap  that  it  should  contain 
on  its  margin  some  hairs  of  eyebrows.  This  ingenious  conceit, 
like  many  others,  though  laudable  in  purpose,  would  rarely 
accomplish  more  than  to  mar  an  eyebrow,  and  form  an  unsightly 
eyelash.  The  w^ork  will  be  better  done  by  him  who,  in  the 
probably  near  future,  learns  to  transplant  hair  bulbs. 

In  case  the  lachrymal  sack  must  be  opened,  and  its  wall  so 


494  DISEASES    OF    THE    EYELID. 

destroyed  tliat  there  will  be  an  escape  of  tears  afterwards,  a 
recourse  may  be  had  to  removal  of  the  lachrymal  gland.  It  has 
been  found  that  the  conjunctiva  retains  its  moisture  though  this 
gland  be  absent.  Tiie  moisture  is  maintained  by  the  secretion 
from  ghmds  which  exist  in  the  cul-de-sac,  or  concealed  recess  of 
the  conjunctiva.  In  fact,  the  secretion  of  tears  is  intermittent, 
only  occurring  under  the  influence  of  emotion,  or  an  irritation  of 
the  membrane:  for  example,  from  a  foreign  body  lodged  in  the 
eye.  These  structural  conditions  i)ermit  the  eye  to  dispense 
with  the  lachrymal  gland,  in  case  some  defect  in  tlie  tear- 
conducting  passage  may  demand  the  removal  of  the  former. 

The  lachrymal  gland  was  thus  extirpated  by  the  writer  in  a 
case  in  which  the  lachrymal  sack  was  destroyed  in  an  operation 
for  the  removal  of  a  cancerous  growth.  The  work  was  done  by 
extending  the  outer  commissure  by  a  horizontal  slit;  thus  the 
upper  lid  was  uplifted  in  its  outer  half,  and  the  gland  extir- 
pated. Instead  of  elongating  the  outer  angle,  the  work  may  bo 
done,  as  Tillaux  advises,  through  an  incision  made  horizontally 
above  the  external  angular  process  of  the  frontal  bone;  this  cut 
is  made  an  inch  long,  through  all  the  soft  parts  to  the  bone. 
These  parts,  including  the  periosteum,  are  then  to  be  reflected 
downwards,  following  the  bone  into  the  orbit,  until  the  gland  is 
reached.  This  lies  between  two  layers  of  the  periosteum,  one  of 
which  separates  the  gland  from  the  bone,  and  the  other  layer 
separates  it  from  the  conjunctiva.  Through  such  a  route  the 
gland  can  be  reached  and  removed  without  entering  the  cavity 
of  the  conjunctival  pouch.  It  will  facilitate  the  operator  greatly 
in  this  work  if  he  precede  his  operation  on  the  living  subject  by 
one  on  the  cadaver.  To  distinguish  the  structure  of  the  gland 
from  adipose  tissue  is  not  so  easy  as  the  inexperienced  might 
suppose.  Without  occasional  anatomical  rehearsal,  facts  which 
have  been  firmly  fastened  in  memory  become  loosened  and 
obscure.  The  site  and  relation  of  parts,  however  firml}^  chained 
in  the  mental  field,  gradually  relax  their  tethering.  These 
conditions  and  limitations  of  our  knowledge  demand  attention, 
whenever  the  surgeon's  scalpel  essays  an  unfamiliar  task. 

Tumors  Arising  from  the  Orbital  Wall. — The  bon}-  wall  of  the 
orbit  is  the  occasional  site  of  tumors  which  demand  curgical 
intervention;  as  such  may  be  mentioned  the  osteoma  and  the 
myxoma. 

Examples  of  the  osteoma  springing  from  the  bony  wall  have 
been  observed,  in  which  the  growth,  not  being  interfered  with, 


TUMORS    ARISING    FROM    THE    ORBITAL    WALL.  495 

attained  such  size  as  to  crowd  on  tlie  eyeball  and  disturb  or  even 
destroy  vision.  Such  osseous  growth  ma}'  spring  from  any  por- 
tion of  the  wall;  or  it  inay  arise  from  one  of  the  adjacent  fossae, 
as  the  frontal  or  maxillary,  and  proceed  thence  towards  the 
orbital  cavity.  The  growth  may  spring  from  the  bone  or  from 
its  investing  periosteum.  In  structure  it  may  be  similar  to  nor- 
mal bone,  or  it  may  be  of  ivory  hardness.  The  pedicle,  when 
sucli  exists,  has  but  little  tendency  to  enlarge;  the  growth  is 
more  eccentric,  and  may  attain  considerable  dimensions;  one 
removed  by  Maisonneuve  measured  seven  inches  in  circumfer- 
ence. On  section,  the  normal  osseous  tumor  presents  cartilagi- 
nous content;  but  when  it  is  of  the  eburnated  or  ivor}"  species,  it 
is  wholl}^  solid.  This  eburnated  osseous  tumor  arises  nearly 
always  from  the  ethmoid  or  frontal  bone.  "When  divided  by  the 
saw,  it  presents  a  stratified  appearance.  It  is  probable  that  the 
ivory  form  differs  only  from  normal  osseous  tumor  in  being 
older;  that  is,  it  has  become  hardened  by  greater  age. 

The  intra-orbital  osteoma  wdien  seated  deep  may  remain  for 
some  time,  without  any  visible  indication  of  its  existence,  except 
some  pain  in  the  eye;  later,  the  bulb  protrudes;  signs  of  com- 
pression on  both  vessels  and  nerves  become  then  more  manifest; 
the  eye  is  congested  aiid  painful,  and  as  the  tumor  enlarges,  it 
forces  the  eye  in  a  direction  opposite  to  the  site  of  the  growth. 
And  this  deviation  aids  in  diagnosing  the  tumor's  location. 

Treatment. — The  intra-orbital  osseous  tumor,  w'hen  of  small 
volume,  and  when  it  has  ceased  to  grow,  may  be  allowed  to 
remain;  the  removal  of  it  would  cause  more  disturbance  to  the 
eye  than  the  osteoma  itself.  It  is  seldom  that  it  has  this  harm- 
less character;  for,  continuing  to  grow,  its  encroachment  on  the 
eye  will  finally  prove  fatal  to  that  organ.  Thus  Textor  saw^  and 
operated  on  a  case,  in  1865,  wdiich  had  reached  the  enormous 
volume  of  a  child's  head;  the  tumor  had  crowded  on  and  wholly 
destroyed  the  eye.  Textor  removed  this  tumor  by  splitting  it, 
and  extracting  the  fragments  in  sections.  There  remained  a 
great  breach,  opening  into  the  nose,  and  antrum  of  the  upper 
ja-w.  AVith  hints  from  the  disaster  wdiich  may  result  from  per- 
mitting such  developing  tumor  to  pursue  its  own  course,  it  should 
be  removed  early.  And  this  is  done  by  a  horizontal  incision 
through  the  attached  portion  of  the  lid;  or,  instead  of  this,  a  route 
may  be  made  by  slitting  outw^ards  the  external  commissure.  By 
one  of  these  routes  carried  inwards  alongside  of  the  bony  wall, 
the  growth  can  be  reached  and  detached  from  the  wall,  by  means 


496  DISEASES    OF    THE    EYELID. 

of  ii  chisel  and  mallet,  or  a  gouge ;  and  if  the  growth  be  volumi- 
nous, it  should  be  divided  with  a  resection  saw  or  bone  forceps. 
The  base  or  pedicle  should  be  wholly  removed,  so  as  to  prevent 
recurrence. 

A  growth  similar  to  the  osteoma  is  the  osseous  cyst.  An 
example  of  this  kind  has  fallen  under  the  observation  of  the 
writer.  This  was  seated  in  the  inner  portion  of  the  orbit,  occupy- 
ing a  quadrant  of  the  orbital  margin.  It  was  mistaken  for  a  solid 
osseous  tumor  until  its  true  nature  was  revealed  by  the  operation 
undertaken  for  its  removal.  The  tumor  was  found  to  have  a 
wall  less  than  a  line  thick,  and  to  be  filled  with  a  myxomatous 
material,  and  more  than  a  half  ounce  in  amount.  The  cavity,  in 
which  this  was  contained,  reached  upwards  into  the  frontal  bone, 
and,  internally,  it  occupied  the  right  lateral  mass  of  the  ethmoid 
bone.  The  lachrymal  bone  was  uplifted  and  formed  a  part  of 
the  wall  of  the  tumor.  A  section  of  the  right  nasal  bone  was 
likewise  uplifted.  The  structure  and  connections  of  the  tumor 
were  such  that  in  its  removal  a  breach  was  made  into  the  contigu- 
ous bones.  The  removal  was  done  through  a  semilunar  incision 
with  concavity  looking  outwards  and  somewhat  downwards;  and 
the  investing  soft  parts  were  carefully  uplifted,  and  afterwards 
reclosed,  over  the  breach,  by  metallic  sutures.  Drainage  was 
maintained  through  a  tube,  of  which  the  lower  end  pas.sed 
through  the  right  nasal  passage,  escaping  through  the  nostril. 
Through  this  tube  the  cavity  of  the  wound  was  daily  cleansed  b\' 
irrigation.  The  wound  healed  rapidly,  and  tlie  skin,  wdiich 
closed  it,  did  not  sink  so  as  to  disfigure  the  boy's  face.  The  tear 
pa.ssage  into  the  nose  was  wholly  destroyed  in  the  operation. 
Yet  the  secretion  found  its  way  through  the  remaining  canalic- 
ulus into  tlie  breach  which  had  been  made.  After  a  period  of 
two  years  there  was  no  recurrence  of  this  growth,  though  the 
myxomatous  nature  of  the  neoplasm  rendered  it  probable  that 
the  operation  would  give  but  temporary  relief 

Tumors  Originating  within  the  Orbit. — Tumors  benign  as  well 
as  malignant  arise  w^ithin  the  orbit.  Of  the  benign  species  the 
lipoma  and  fibroma  occur  here. 

The  lipoma  has  been  observed  here  in  a  few  cases;  its  more 
frequent  occurrence  might  have  been  suspected,  when  one  takes 
into  account  the  adipose  couch  on  which  the  globe  of  the  eye 
rests.  Such  growth  when  verified  should  be  removed  througli 
an  incision  made  in  a  properly  selected  site.  A  drainage  tube 
of  small  calibre  should  be  introduced  in  most  cases,  and  a  com- 


TUMOES    ORIGIXATIXG    ^VITHIX    THE    ORBIT.  497 

press  saturated  with  cold  water  should  be  retained  on  the  eye  for 
a  few  days. 

The  fibroma  occurs  as  an  orbital  tumor,  and,  like  the  lipoma, 
it  is  slow  in  its  developmeut.  It  may  become  so  large  as  to  fill 
the  orbit  and  destroy  the  eye.  It  may  likewise  present  eccentric 
development,  and  penetrate  the  adjacent  cavity  of  the  nose,  or 
the  frontal  or  maxillary  sinus.  This  tumor  arises  from  the 
periosteal  covering  of  the  orbital  wall;  and,  also,  some  claim,  from 
the  fibrous  sheath  of  the  optic  nerve.  The  treatment  should  be 
similar  to  that  of  the  lipoma,  viz.,  removal  with  the  knife. 

Ryba,  in  1853,  described  a  wartlike  growth  arising  from  the 
ocular  conjunctiva,  which  was  probably  fibromatous  in  character. 
Four  cases  were  seen  in  man  and  two  in  the  eyes  of  animals. 
This  growth  was  white,  yellowish  or  reddish  wdiite  in  hue,  and 
was  covered  with  hairs  of  different  lengths,  color  and  size.  Some 
of  the  tumors  which  were  examined  were  found  to  resemble 
normal  skin  which  produces  hairs.  And  from  this  dermal 
resemblance  Ryba  proposes  as  name  for  this  tumor,  conjunctival 
dermoid  tumor.  Perhaps  it  may  be  a  heterotopic  production  of 
embryonic  life,  in  which  fragmentary  segments  of  derm  have 
become  displaced. 

The  proper  treatment  of  this  dermal  fibroid  is  through  extir- 
pation; and,  to  prevent  recurrence,  there  should  be  applied  to 
the  site  of  the  operation  some  astringent  application,  as  the  sul- 
phate of  copper,  or  nitrate  of  silver;  likewise  the  tincture  of 
opium  may  be  applied. 

Sarcoma  and  epithelial  and  melanotic  cancer  have  their  origin 
in  the  soft  parts  of  the  eye. 

A  form  of  sarcoma  seen  by  several  observers  presents  numer- 
ous small  cavernous  spaces  in  its  structure,  and  from  this  cir- 
cumstance, it  has  been  denominated  cavernous  fibroid.  Accord- 
ing to  Virchow,  it  has  its  origin  in  the  adipose  tissue  of  the 
orbit.  It  is  usually  seen  in  the  young  subject.  Through 
encroachment  on  the  bulb,  exophthalmos  finally  arises.  It  may 
send  prolongations  into  the  adjacent  cranial,  nasal  or  maxillary 
cavities,  and,  through  pressure,  cause  functional  disturbance  in 
these  situations.  This  tumor  rarely  ulcerates,  nor  is  it  attended 
by  the  cachexy  of  cancer. 

The  proper  treatment  is  radical  extirpation;  yet  the  removal 
is  commonly  followed  by  a  regrowth  of  the  tumor.  Xelaton, 
Pean  and  others  report  cases  of  sarcoma  in  the  orbit,  in  which 
there  was  recurrence,  and  repeated  operations  were  done.     The 


49S  DISEASES   OF    THE    EYKLID. 

author  has  observed  three  cases,  all  in  children,  in  whom  there 
was  a  recurrence,  and  repeated  operations  were  done  until  death 
occurred  from  exhaustion.  In  order  that  the  removal  should  be 
done  as  etfectually  as  possible,  the  work  of  the  scal[)el  should  be 
followed  by  that  of  the  thermal  cautery.  The  actual  cautery  can 
scarcely  be  employed  with  safety  where  the  eye  is  retained,  lest 
the  latter  be  endangered;  also,  when  heat  is  employed  in  the 
upper  part  of  the  orbit,  the  thinness  of  the  supra-orbital  plate 
should  be  remembered. 

Epithelial  cancer  may  commence  in  the  lid;  more  frequently 
it  is  an  immigrant  from  contiguous  structures  which  were  pri- 
marily attacked;  and  in  the  latter  case,  the  most  frequent  site  of 
the  growth  is  the  derm  of  the  adjacent  side  of  the  nose.  The 
writer  has  seen  many  cases  in  which  the  epithelioma  appeared 
secondarily  in  the  eye;  attacking  then  the  lid,  or  entering  the 
commissure,  the  disease  appeared  on  the  conjunctiva.  In  several 
cases  the  epithelioma  began  on  the  cheek  and  traveled  thence 
to  the  lower  eyelid.  In  all  these  cases,  the  growtli  commences 
as  a  slight  elevation  of  the  surface,  of  rounded  border,  and  con- 
sists of  a  multiplication  of  the  epithelial  strata.  This  initial 
growth  has  a  whitish  aspect,  and,  if  the  epidermal  covering  be 
removed,  the  subjacent  papillary  layer  will  be  seen  to  be  prom- 
inent. Such  a  growth  commences  to  disintegrate  at  its  central 
point,  and  as  this  ulcer  enlarges,  the  peripheral  border  advances. 
It  develops  peripherally;  and  if  near  a  palpebral  commissure, 
the  advance  is  more  rapid  in  tliat  direction  than  elsewhere. 

The  treatment  should  be  removal  of  the  growth  with  the 
knife,  or  its  destruction  by  cauterization.  If  the  knife  be 
resorted  to,  it  should  be  used  early  and  unsparingly.  The 
author  has  been  taught  by  unfortunate  experience  that  econo- 
mizing the  tissues  for  the  purpose  of  avoiding  a  scar  is  certain 
to  be  followed  by  a  return  of  the  epithelioma;  and,  to  shun  this, 
if  excision  be  resorted  to,  let  it,  besides  including  the  affected 
structure,  pass  three  or  four  lines  be3^ond  into  the  sound  surface. 

Unfortunately,  malignant  disease  does  not  limit  itself  to  the 
superficial  species  here  described,  and  carcinoma  of  the  most 
intractable  character,  viz.,  melanotic  cancer,  frequently  attacks 
the  eye.  This  growth  occurs  in  childhood  and  youth,  and  is 
seldom  seen  in  mature  or  advanced  age.  Melanoma,  as  the  dis- 
ease is  designated  by  the  pathologist,  has  been  the  subject  of 
disagreement  among  those  who  have  clinically  studied  this 
growth;  while  many  have  pronounced  it  eminently  malignant, 


TUMORS    ORIGINATING   WITHIN    THE    ORBIT.  499 

others  declare  it  curable  by  an  operation;  thus  Pamard,  in  1853, 
finding  that  the  disease  did  not  recur  after  removal,  decided  that 
it  is  not  malignant ;  on  the  contrary,  Stoeber  found  that  it 
recurred,  and  reappeared  metastatically  in  distant  parts,  viz.,  in 
the  liver. 

Sichel,  in  1856,  in  his  study  of  melanoma  seated  in  the  orbit, 
found  that  the  disease  commences  in  the  fundus  of  the  •eye; 
thence  it  grows  forwards,  and  finally  pierces  the  anterior  wall. 
The  melanotic  material  was  found  to  be  similar  to  that  contained 
in  the  choroid  membrane,  and  in  this  matter  were  found  carbon 
and  iron. 

St.  Lager  and  Hervier  think  that  melanotic  material  arises 
from  an  excessive  production  of  the  normal  pigment  of  the  body. 
When  the  melanoma  occurs  in  other  parts  of  the  body,  these 
writers  find  that  it  may  be  encysted  or  non-encysted;  and  in  some 
cases  it  may  appear  in  liquid  form;  also  in  the  form  of  a  mem- 
brane 

The  writer  has  seen  a  few  cases  of  melanoma  seated  in  tlie 
eye;  and  all  were  in  children.  In  its  early  stage,  since  it  is  then 
painless,  it  may  escape  detection  for  a  time;  later,  the  eyeball 
protrudes  until,  finally,  the  lids  cannot  be  closed;  and,  at  length, 
the  distended  ball  bursts  at  some  point,  and,  through  the  rent, 
there  is  forced  out  the  gelatinous  melanoid  material  character- 
istic of  the  tumor.  The  site  of  the  rupture  is  commonly  in  the 
anterior  portion  of  the  sclerotic  coat.  When  the  disease  has 
reached  this  stage,  its  most  remarkable  feature  is  rapidity  of 
growth.  Vision  is  lost  at  an  early  period.  Like  all  rapidly 
developing  malignant  growths,  there  is  an  absence  of  glandular 
afi'ection. 

Heyfelder  and  other  surgical  authorities,  who  have  written  on 
the  treatment  of  malignant  disease  of  the  eye,  advise  an  early 
removal  of  the  affected  part ;  thus  doing,  Heyfelder  thinks  it  pos- 
sible to  preserve  the  eye.  This  conservative  action,  the  writer  is 
convinced,  is  rarely  the  proper  one;  he  has  never  had  to  regret 
too  extensive  excision;  but  pursuing  the  contrary  method  has,  in 
several  cases,  been  followed  by  a  recurrence  which  brought  with 
itself  the  necessity  of  a  more  wholesale  sacrifice  than  primarily 
would  have  been  necessary.  Whether  a  cell,  liquid  content,  or  a 
microphyte  be  the  factor  of  propagation,  this  agent  soon  finds 
un.guspected  lodgment  in  the  contiguous  structures,  too  often 
beyond  the  line  of  excision.  Hence,  as  a  guiding  rule  in  all 
cases  of  malignant  disease  situated  in  the  structures  which  lie 


500  DISEASES    OF    THE    EYELID. 

around  the  eye  within  tlie  orbit,  the  bulb,  including  the  intra- 
orbital tissue,  should  be  removed.  And  the  same  rule  should  be 
followed  if  the  case  be  melanotic  cancer  affecting  the  eyeball. 
Enucleation,  with  retention  of  a  portion  or  the  entirety  of  the 
•ocular  muscles,  so  that  an  artificial  eye  may  be  worn,  is  nearly 
always  followed  by  a  reappearance  of  the  disease.  This  has  been 
verified  several  times  in  the  author's  practice.  Excision  conserv- 
atively done  was  followed  by  recurrence,  demanding  a  second, 
and  then  a  third,  and  a  fourth  operation,  until  nothing  more 
remained  to  remove.  His  experience  leads  the  writer  to  formu- 
late the  rule  that,  wherever  the  ocular  tissues  have  become  the 
seat  of  sarcomatous  or  carcinomatous  disease,  the  knife  should 
only  be  stayed  by  the  naked  walls  of  the  orbit.  In  work  thus 
done,  the  bare  bony  wall  does  not  become  necrosed,  as  might  be 
exi>ected,  but  it  becomes  covered  with  a  cicatricial  investment. 
Should  the  bony  wall  be  attacked,  then  the  affected  surface  should 
be  removed  with  a  chisel  or  gouge,  and  the  remaining  structure 
be  thermally  cauterized.  The  cautery  must  not  be  applied  to  the 
supra-orbital  plate,  lest  the  heat  should  injure  the  superjacent 
cerebrum.  The  writer  has  known  death  to  occur  from  such  inad- 
vertency. 

Foreign  Bodies  in  the  Eije. — From  the  grave  aff'ections  of  the 
eye  just  considered,  the  writer  passes  by  a  pleasant  transition  to  a 
matter  of  minor  moment;  this  is  a  foreign  body  which  has  acci- 
dentally lodged  on  the  surface  of  the  eye,  the  removal  of  which 
often  calls  forth  an  outburst  of  gratitude  from  the  relieved  patient. 
The  pain  from  this  corpuscular  object  is  greater  when  it  is  lodged 
between  the  bulb  and  the  lid  than  when  it  lies  on  the  free  surface. 
The  pain  is  very  acute  when  the  object  has  become  imbedded  in 
the  exposed  portion  of  the  cornea.  A  grain  of  sand  or  iron  when 
lodged  in  the  eye,  if  rough  in  surface,  as  it  usually  is,  is  extremely 
painful,  and,  owing  to  the  insolubility  of  such  object,  it  will  con- 
tinue to  irritate  until  the  object  is  removed. 

Of  all  the  objects  which  lodge  in  the  eyeball,  there  is  none 
more  perilous  than  the  arista,  or  awn,  of  certain  grains.  This 
awn,  or  beard,  as  it  is  familiarly  called  among  farmers,  is  the 
sharp  projecting  process  in  which  ends  the  husk  containing  the 
grain  of  barley,  rye,  wheat  and  oats.  This  little  object,  barbed 
as  it  is  laterally,  when  it  becomes  entangled  in  the  conjunctival 
structure,  tends  to  penetrate  and  become  faster  in  its  hold.  And 
the  danger  is  especially  great  when  the  awn  has  entered  the 
cul-de-sac  of  the  conjunctiva,  and  has  become  concealed  through 


FOREIGN    BODIES    IN    THE    EYE.  501 

swelling  of  the  conjunctival  tissue.  In  such  a  case  the  move- 
ment of  the  eyeball  and  the  compression  and  motion  of  the  lid 
tend  to  bury  the  object  and  wholly  conceal  it.  Thus  situated, 
the  awn  has  led  to  suppuration  and  destruction  of  the  cornea. 

Treatment. — In  the  case  of  an  object  wdiich  is  of  smooth 
surface,  the  irritation  awakened  acts  reflexly  on  the  lachrymal 
gland  and  causes  profuse  lachrymation,  and  the  object  may  thus 
be  floated  out  of  the  eye.  To  aid  in  this  washing  out,  the  patient 
should  close  his  eyelids  until  the  tears  have  collected  under- 
neath; then,  suddenly  opening  the  eye,  the  offender  may  be 
borne  away  in  escaping  flood.  Or  with  a  little  self-control,  if 
the  eye  be  committed  to  its  own  unaided  actions,  the  object  may 
be  expelled  spontaneously. 

But  if  the  object  be  a  fragment  of  metal  or  a  cinder  or  grain 
of  sand  with  sharp  edges,  and  is  partially  embedded  in  the 
corneal  or  conjunctival  structure,  then  the  removal  demands 
address  and  tact  on  the  part  of  the  surgeon.  The  first  act  will 
be  to  prepare  the  eye  for  manipulation  by  applying  to  it  a  five 
per  cent  solution  of  muriate  of  cocaine.  Such  a  solution  in  ten 
minutes  deprives  the  eye  of  sensation,  so  that  the  bulb  can  be 
touched,  and  no  pain  or  unpleasant  feeling  is  experienced  by  the 
patient.  The  patient  should  also  be  told  that  the  cocainized  eye 
wall,  through  the  mydriatic  action  of  the  agent,  be  rendered 
unfit,  for  a  short  time,  for  common  vision;  this  will  vanish  in  a 
few  hours.  If  not  visible,  the  object  must  be  searched  for  by 
turning  each  lid  outwards.  The  patient  is  rarely  able  to  locate 
the  object  correctly.  To  search,  draw  down  the  lower  lid,  while 
the  patient  rolls  the  ball  upwards.  If  not  found  there,  evert  the 
upper  lid  by  folding  it  on  the  proximal  border  of  the  tarsal 
cartilage,  or  which  may  aptly  be  called  the  joint  of  the  upper 
lid.  During  upward  eversion,  the  eye  should  be  directed  down- 
wards, since  thus  the  superior  conjunctival  pocket  will  be 
unfolded,  and  its  complete  exploration  is  easily  done.  In  the 
majority  of  cases,  the  body  will  be  found  adherent  to  the  pal- 
pebral conjunctiva.  The  object  is  usually  of  gray  or  black  hue, 
thus  contrasting  with  the  red  color  of  the  deeply  injected  con- 
junctiva. 

AVhere  the  object  is  non-adherent  and  merely  lies  on  the  eye- 
ball or  the  lid,  it  can  readily  be  wiped  off  with  a  soft  linen  or 
silken  cloth;  but  if  it  has  fixed  itself  in  the  corneal  or  con- 
junctival structure,  the  removal  is  more  difficult.  In  such  a 
case,  if  the  particle  be  lodged  in  the  bulb,  it  will  be  necessary  to 


502  DISEASES    OF    THE    EYELID. 

fix  this  by  means  of  forceps.  The  blades  of  the  forceps  should 
be  smooth  and  not  serrated,  since  the  latter,  in  tlieir  clasp, 
wound  the  structure.  The  cocainized  bulb  being  thus  caught 
and  held,  the  foreign  body  is  to  be  detached  with  the  needle- 
pointed  instrument  used  by  the  oculist  for  discission  of  the 
cataractous  lens.  If  the  object  be  fixed  in  the  cornea,  the 
detaching  needle  should  be  passed  under  one  of  its  sides,  and 
then  uplifted.  In  case  the  body  be  a  })article  of  iron  which 
leaves  a  stain  of  rust  on  the  cornea,  this  stain  should  be  carefully 
removed  with  the  detaching-needle;  since,  if  allowed  to  remain, 
the  iron  rust  may,  like  a  salt  of  lead  or  silver,  become  afterwards 
incorporated  with  tlie  corneal  tissue.  After  such  manipula- 
tion, the  eye  should  be  covered,  for  some  hours,  with  a  compress 
wet  in  cold  water. 

In  case  the  irritating  body  is  not  found,  and  is  suspected  to 
be  lodged  in  the  bottom  of  the  conjunctival  pocket,  that  recess 
must  be  diligently  explored.  Such  search  is  often  rewarded  by 
discovery  of  the  irritating  body.  If  the  fatal  awn  of  a  member  of 
the  Graminese  be  hidden  there,  its  presence  will  soon  be  revealed 
by  tumefaction  in  the  part, from  local  conjunctival  inflammation; 
and  in  the  midst  of  the  pouting  swollen  tissue,  the  object  is  buried. 
Likewise,  particles  of  exploded  molten  metal  may  enter,  and 
remain  hidden  in  this  conjunctival  cul-de-sac.  To  aid  in  the 
search,  after  eversion  of  the  lid,  the  rounded  end  of  a  silver  ])robe 
may  be  used;  thus  metal  is  readily  detected.  I'he  history  of  the 
case  must  give  some  indication  of  the  object  to  be  sought  for; 
especially,  if  the  eye  has  been  injured  by  melted  metal.  Again, 
if  a  child,  whose  sports  expose  him  to  the  awned  Graminea?, 
becomes  suddenly  affected  with  tumefaction  of  one  or  both  eye- 
lids, a  pretty  accurate  guess  of  the  causal  agent  can  be  made; 
and  in  such  case  the  tumefied  structure  should  be  thoroughly 
searched. 

Tlie  barbed  sides  of  the  awn  favor  advance  and  not  return 
of  the  object;  and  thus,  after  a  time,  it  invariably  buries  itself, 
and,  if  not  found  and  extracted,  it  will  later  reveal  itself  in  a 
shred  of  gangrenous  tissue,  when  the  eye  has  been  lost  through 
destruction  of  the  cornea;  to  avert  sucli  a  catastrophe,  the  sur- 
geon must  early  fi.nd  and  remove  the  destructive  agent. 


CHAPTER  XIV. 

SURGERY     OF    THE     MALAR     AND     PAROTIDEAX     REGIONS     OF     THE 

FACE. 

A  LARGE  portion  of  this  region  of  the  face  in  the  male  is  cov- 
ered with  beard ;  the  surface  thus  invested  varies  in  individuals. 
Paucity  of  beard  is  a  characteristic  of  the  Mongolian  race.  The 
subcutaneous  adipose  couch  over  the  most  of  these  regions  is 
closely  adherent  to  the  derm;  this  is  especially  true  of  the  malar 
region;  and,  owing  to  this  fact,  the  derm  here  is  not  well  suited 
for  operative  plastic  work.  Commencing  in  front  of  the  parotid 
gland,  contiguous  to  the  parotidean  duct,  lies  a  layer  of  adeps, 
which  is  augmented  in  mass  in  front  of  the  masseter  muscle; 
and  this  adeps,  lodged  beneath  the  front  border  of  the  masseter, 
loosel}'  surrounds  the  terminal  end  of  the  parotidean  duct.  Ten- 
sion of  the  duct  is  thus  lessened,  and  the  discharge  of  the 
escaping  saliva  is  not  hampered  by  the  varying  volume  of  the 
masseter  in  mastication.  The  muscles  situated  in  these  regions 
may,  when  functionally  considered,  be  divided  into  two  classes. 
In  the  one  class  concerned  in  mastication  are  the  masseter  and 
buccinator;  while  the  other  group  comprises  muscles  which, 
besides  lifting  and  depressing  the  lips,  are  mainly  concerned  in 
emotional  and  other  mental  manifestations.  These  muscles  con- 
cerned in  expression  are  imbedded  in,  and  adherent  to,  the 
subcutaneous  adipose  tissue,  and  they  differ  from  most  muscles 
in  having  no  sheaths  within  which  they  can  glide;  and,  hence, 
wounds  severing  these  muscles,  gape  but  little.  If  the  surface  of 
the  face  be  examined  in  the  adult,  and  especially  in  the  aged 
subject,  certain  furrows  will  be  found,  which  arise  from  the 
action  of  underlying  muscles.  There  are  three  series  of  such 
furrows;  the  first  series  is  situated  on  each  side  of  the  root  of  the 
nose;  a  second  series  on  each  side  of  the  wings  of  the  nose,  and 
the  third  includes  the  angles  of  the  mouth.  Attention  to  the 
site  of  these  furrows  is  necessary  in  certain  plastic  procedures  in 
this  region.     Lines  of  incision  following  such  normal  furrows  will 

(503) 


504  MALAK    AND    PAROTIDKAN    EEGIONS. 

leave  less  conspicuous  cicatrices.  Thus  the  adroit  plastician 
hides  the  vestiges  of  his  work  in  the  footprints  wliich  time  lias 
left,  or  will  leave,  on  the  human  face. 

The  supply  of  blood  to  this  region  is  mainly  derived  from 
the  facial  and  the  transverse  facial  branches  of  the  external 
carotid, and  from  the  temporal  arteries.  The  deeper  structures  be- 
low the  eye  are  supplied  b}^  the  infra-orbital  artery;  thus  they  get 
their  blood  by  a  circuitous  intra-cranial  route  from  the  internal 
carotid.  The  variability  of  volume  of  the  facial  arter}^  should  be 
remembered;  it  often  reaches  tlie  ala  of  the  nose  as  a  vessel  of 
moderate  calibre;  or  it  may  be  so  attenuated  on  the  side  of  the 
face  as  scarcely  to  demand  a  ligature  if  it  be  opened.  The 
arteries  of  the  face  are  remarkable  for  tlieir  intercommunication; 
they  anastomose  freely  among  themselves,  and  also  with  the 
arteries  of  the  opposite  side.  Hence,  compression  of  the  facial 
artery,  where  it  lies  on  the  lower  jaw,  as  is  sometimes  done  to 
control  bleeding  during  operations  on  parts  supplied  by  its 
branches,  controls  the  haemorrhage  only  imperfectly;  torsion  or 
ligation  should  be  done  at  the  site  of  injury. 

The  facial  region  is  traversed  by  the  facial  vein,  which  soon 
acquires  some  magnitude;  this  vessel  is  found  below  the  inner 
angle  of  the  eye  and  passes  down  from  that  point  to  the  angle  of 
the  lower  jaw,  where  it  turns  inwards  to  meet  and  end  in  the  inter- 
nal jugular  vein.  The  facial  vein  lies  behind  the  facial  artery;  a 
slight  interval  separates  the  two  until  they  roach  the  anterior 
inferior  angle  of  the  masseter  muscle;  here  they  lie  close  to  each 
other.  In  their  transit  on  the  face  the  artery  and  vein  lie  on  the 
buccinator,  and  beneath  the  zygomatic  muscles. 

The  terminal  branches  of  the  facial  nerve  are  distributed  to 
the  muscles  of  the  face;  and  if  one  or  more  of  these  branches  be 
severed,  there  will  follow  a  corresponding  palsy  of  the  parts. 

Wounds  of  the  Clucek  and  Side  of  the  Face. — The  exposed  situa- 
tion of  the  cheek  and  the  side  of  the  face  renders  this  region  the 
frequent  site  of  injuries.  Such  lesions  are,  most  frequently, 
laceration  and  contusion,  and  the  incised  wound.  The  gunshot 
wound  has  occasionally  its  site  here;  and,  oftener  than  the  pro- 
jected missile,  the  powder  leaves  traces  of  its  action  on  the 
skin. 

Contusion  without  laceration  is  frequent.  In  this  injury  the 
tearing  of  the  subcutaneous  vessels  pours  out  blood,  whence 
isolated  swelling  quickly  occurs.  The  amount  of  the  tumefac- 
tion is  a  fair  measure  of  the  grade  of  violence.      If  the  bruise 


WOUNDS    OF    CHEEK    AND    SIDE    OP    FACE.  505 

be  on  the  lower  part  of  the  cheek,  the  tumefaction  will  be 
confined  to  that  part;  but  if  the  injury  be  near  the  eye,  the 
effused  blood  quickly  finds  its  way  to  the  eyelids,  which  often 
swell  so  as  to  close  the  eye.  This  frequent  result  of  facial  con- 
tusion is  one  of  its  most  disagreeable  accompaniments;  for  the 
"black  eye,"  as  it  is  called,  socially  banishes  its  owner  for  a  few 
days.  Also  the  effused  blood  often  leaves  at  the  point  where  it  is 
poured  out  an  induration  and  enlargement  for  a  long  period. 
Hence,  from  the  circumstances  mentioned,  the  facial  contusion  is 
sufficiently  important  to  demand  careful  treatment.  The  objects 
aimed  at  by  the  treatment  should  be  to  prevent  the  effusion  of 
blood,  or,  if  effused,  to  favor  its  dispersion  and  absorption.  If  the 
case  be  seen  at  its  onset,  the  escape  of  blood  into  the  tissues  may 
be  impeded  by  methodical  pressure  made  over  the  injured  part. 
For  this  a  sheet  of  paper  folded  into  a  compress  and  laid  on  the 
part  and  retained  there  for  twenty  hours,  by  means  of  broad 
strips  of  adhesive  plaster  and  a  roller,  will  prevent  further  effu- 
sion. But  if  the  effusion  has  occurred,  then  dispersion  can  be 
accomplished  by  massage  or  kneading  the  part;  and  in  this  work, 
as  far  as  is  possible,  the  material  should  be  forced  from  the  ej^e- 
lids.  In  the  event  of  there  being  a  considerable  collection  of 
blood  already  effused,  direct  evacuation  of  this  has  sometimes 
been  done  through  an  opening  made  through  the  skin;  the 
experience  of  any  surgeon  will  pronounce  against  this  way 
of  proceeding,  since,  despite  aseptic  precautions,  suppurative 
action  often  ensues  and  a  tedious  healing  with  scarring  is  the 
result.  Should,  however,  the  effused  blood  be  near  the  oral 
cavity,  an  intra-buccal  incision  might  be  made  through  which 
the  blood  could  be  evacuated. 

In  case  the  wound  be  a  laceration  with  contusion,  the  effused 
blood  finding  outlet  does  not  require  attention  as  in  the  j^receding 
case  ;  but  the  torn  wound  must  be  treated  wuth  unusual  care  to 
avoid  a  disfiguring  mark ;  and,  for  this  purpose,  the  fringed 
borders  must  be  carefully  trimmed  off~-  and  the  edges  accurately 
coaptated  by  fine  catgut  or  metallic  suture,  after  the  wound  has 
been  well  washed  with  a  sublimated  alcoholic  solution.  The 
wound  should  afterwards  be  covered  with  a  compress,  which  must 
constantly  be  retained  moist  with  the  same  solution.  Sometimes 
the  author  has  dressed  with  lint  saturated  with  the  compound 
tincture  of  benzoin,  wdiich  is  placed  and  retained  on  the  part 
with  adhesive  plaster.  Thus  union  with  slight  scarring  may 
sometimes  be  obtained;  yet  there  is  more  danger  of  failure  from 
33 


506  MALAR    AND    PAROTIDEAX    REGIONS. 

suppuration  tliau  if  llie  moist  dressing  just  mentioned  be  used. 
Under  the  benzoated  application  the  sutures  may  remain  longer 
than  the}''  should  under  the  sublimated  alcoholic  dressing;  in  the 
latter  case  the  sutures,  if  metallic,  should  all,  or  nearly  all,  be 
removed  at  the  end  of  the  second  day.  If  catgut  suture  be  used, 
it  rarely  requires  removal,  since  it  usually  disappears  by  absorp- 
tion. When  the  dressing  is  frequently  changed,  there  is  the 
advantage  that  the  condition  of  the  wound  can  be  inspected;  so 
that  if  there  be  signs  of  suppurative  action,  as  shown  by  redness 
and  swelling  of  the  p[irt,  tlien  the  lowest  angle  of  the  wound 
should  be  opened,  and  the  semi-purulent  fluid  allowed  to  escape; 
and  this  escape  will  be  favored  by  the  moist  compress;  thus 
watchfully  treated,  such  a  wound  may  heal  almost  as  rapidly  as 
by  first  intention. 

An  open  contused  wound  of  the  face  may  closely  resemble  an 
incised  one,  viz.,  a  wound  over  ctne  of  the  bony  prominences 
which  has  been  caused  by  a  fall  or  an  attack  with  a  blunt  object, 
as  a  club  or  stone.  The  site  of  such  wound  may  be  the  margin 
of  the  orbit,  the  malar  bone,  the  zygomatic  arch,  and  the  angle 
or  the  margin  of  the  lower  jaw.  The  wounds  of  this  class  some- 
times lie  within  the  domain  of  forensic  medicine;  and  their  causal 
agencies  are  favorite  matters  of  controversy  on  the  part  of  legal 
counselors  in  their  efforts  to  balance  the  scales  of  justice;  efforts 
which  sometimes  rather  jostle  than  adjust  the  equipoise  of  these 
scales.  In  such  cases  the  surgical  expert  should  be  as  blindly 
impartial  as  Themis,  before  whom  he  stands.  Should,  however, 
the  expert  become  a  partisan,  he  debases  his  science,  and  usually 
reveals  his  false  position  by  being  drawn  into  contradictions,  in 
which  disloyalty  to  truth  surely  entangles  him.  The  treatment 
of  such  wounds  is  similar  to  that  of  the  incised  class;  in  most 
cases  the  edges  should  be  trimmed,  and  union  accomplished  by 
sutures.  The  moist  aseptic  dressing  before  mentioned  should  be 
used;  and  if  suppurative  action  impends,  the  sutures  (or  certainly 
some  of  them)  must  at  once  be  removed. 

Incised  wounds  in  the  anterior  portion  of  the  face,  as  a  rule, 
gape  less  than  wounds  in  other  parts  of  the  body.  Bleeding  is 
not  profuse  unless  the  facial  artery  is  severed.  One  or  more  fila- 
ments of  the  facial  nerve  may  be  severed,  and  palsy  of  the 
muscles  which  are  supplied  by  the  injured  nerve  may  result; 
thus  an  awkward  expression  of  the  face  can  originate.  Such 
might  arise  from  a  deep  wound,  running  in  a  vertical  direction, 
that  is,  at  right  angles  to  the  branches  of  the  facial  nerve.     And 


WOUNDS    OF    CHEEK    AND    SIDE    OF    FACE.  507 

this  fact  should  be  borne  in  mind  in  making  incisions  in  this 
region  ;  if  possible  these  should  lie  in  the  horizontal  and  not  in 
the  vertical  plane  of  the  face. 

The  incised  wound  here  is  to  be  treated  in  the  same  way  as 
elsewhere;  bleeding  should  first  be  wholly  arrested,  and  the  mar- 
gins of  the  wound  accurately  apposed  and  retained  so  by  sutures. 
Though  all  wounds  here  bleed  freely  in  consequence  of  free  vas- 
cular inter-communication,  yet,  unless  the  facial  artery  be  opened, 
such  hemorrhage  usually  ceases  spontaneously  if  exposed  to  the 
air  for  a  few  minutes.  Should  some  arteriole  continue  to  bleed 
longer,  the  suture  may  commonly  be  so  introduced  as  to  arrest 
the  bleeding;  to  do  this,  the  suture  must  pass  beneath  the  open 
vessel;  if  it  pass  above  it,  bleeding  continues  unseen  and  sepa- 
rates the  walls  of  the  wound.  Should  the  facial  artery  be 
divided,  it  may  be  closed  by  ligature  or  torsion;  the  author  pre- 
fers the  latter.  The  vessel  should  be  caught  at  its  end  and 
twisted  three  or  four  times  around  its  axis.  The  dressing  should 
be  the  alcoholic  sublimated  compress. 

In  case  of  a  gunshot  wound,  the  missile,  if  lodged,  should  be 
removed  if  it  is  accessible  and  extraction  is  practicable.  The 
removal  of  the  bullet,  if  it  will  not  entail  additional  violence, 
should  be  attempted,  for  such  removal  delights  the  patient, 
pleases  his  friends,  lulls  the  public  clamor  usually  present  for  the 
extraction  of  the  missile,  and  jDossibly  facilitates  the  recovery  of 
the  patient.  The  wound  in  the  soft  parts  should  be  managed 
similarly  to  that  of  an  incised  or  lacerated  wound,  according  as 
it  resembles  one  or  the  other. 

A  lacerated  wound  of  the  cheek,  if  the  causal  agency  be  vio- 
lent, besides  tearing  the  soft  parts,  may  also  fracture  the  subja- 
cent bone.  Such  injury  the  writer  has  treated  a  number  of  times ; 
in  the  most  of  cases  the  cause  was  a  blow  from  a  horse's  hoof;  in 
one  it  was  from  the  thrusting  blow  of  the  horn  of  a  cow,  and  in 
another,  from  the  shaft  of  a  rocket.  The  wound  of  both  soft 
parts  and  the  bone  is  generally  in  the  form  of  a  stellate  rent. 
In  the  adult,  pieces  of  bone  wholly  detached  from  the  soft  parts 
may  be  found  forced  into  the  maxillary  sinus;  this  is  less  often 
in  the  child  and  when  the  antrum  is  but  slightly  developed.  In 
both  the  adult  and  the  child,  the  osseous  fragments  are  generally 
found  adherent  to  the  flap-like  soft  parts.  There  is  commonly 
not  much  bleeding,  and  the  pain  is  not  violent;  since  the  vio- 
lence acts  like  the  ecraseur  in  occluding  the  vessels,  and  by  its 
concussion  deprives  the  sentient  nerves  of  their  sensibility,  the 


508  MALAR    AND    PAROTIDEAX    KKCilOXS. 

liaemorrhage  is  seldom  great,  and  tlie  pain  is  small  in  i»ioportion 
to  the  violence  done. 

The  wounds  of  this  class  necessarily  entail  deformity,  which, 
in  some  instances,  frightfully  alters  the  patient's  face.  In  the 
wound  seen  by  the  author  in  which  a  cow's  horn  was  thrust  into 
the  cheek  of  a  girl,  the  malar  and  superior  maxillary  bones  were 
fragmentarily  broken.  The  cheek  and  lower  eyelid  were  torn, 
with  the  effect  tliat  the  features  on  tliat  side  were  blotted  out 
and  replaced  by  radiating  scars,  and  the  eyelid,  as  a  misshapen 
mass, remained  folded  downwards.  Some  plastic  work,  done  after 
the  wound  had  healed,  somewhat  improved  the  wretched  figure 
of  the  child.  The  wound  caused  by  the  rocket  was  of  a  yet  more 
severe  character;  the  eyeball,  the  lower  lid,  and  a  portion  of  the 
soft  parts  of  the  cheek  were  lacerated.  The  front  face  of  the 
superior  maxilla  was  broken  into  several  pieces.  The  wooden 
shaft  was  left  remaining  in  the  wound,  and,  in  the  attempt  to 
extricate  it  by  some  non-medical  hand,  it  was  broken,  and  a  por- 
tion of  it  remained  behind.  The  first  surgical  aid  endeavored 
to  remove  the  part  imbedded  in  the  skeleton  of  the  face,  and  this 
was  thought  to  be  done  until,  the  wound  not  healing,  further 
search  discovered  another  fragment  of  wood.  After  this  the 
wound  healed,  leaving  a  fragmentary  cheek. 

The  author  would  remark  that  in  all  similar  wounds  on  the 
face  or  elsewhere,  caused  by  the  penetration  of  a  pointed  frag- 
ment of  wood,  in  the  act  of  extraction  there  is  always  a  risk  of 
leaving  a  portion  behind,  especiall}'  if  the  material  be  the  red- 
wood, so  much  in  use  on  the  Pacific  Coast.  If  such  fragment  is 
left,  the  time  of  healing  will  be  indefinitely  prolonged,  and  will 
only  terminate  when  the  wound  has  been  explored  to  its  ultimate 
recess,  and  the  foreign  bod}^  removed. 

The  region  of  the  face  here  under  consideration  is  seldom 
the  site  of  neoplastic  development,  except  the  superficial  angioma, 
which  is  a  frequent  occupant  of  the  cheek.  The  treatment  is 
similar  to  that  which  has  been  heretofore  explained. 

Scrofulous  Ulcer. — There  ai:»pears  here  an  obstinate  form  of 
ulceration,  which  is  analogous  to  tubercular  disease.  In  some 
cases  seen  by  the  writer  this  ulcer  appeared  as  a  single  point;  in 
others,  as  multiple  fjoints  about  the  middle  of  the  clieek,  and 
oftenest  over  the  line  of  the  duct  of  Steno.  The  affection  first 
appears  as  a  soft  tumefaction  of  the  skin,  and  not  exceeding  a 
line  in  breadth.  This  grows  peripherally,  but  does  not  penetrate 
deeper  than   the. skin.     The  outer  portion  of  the  affected  part 


PAROTIDEAX    REGION    OF    THE    FACE.  509 

becoming  detached,  there  remains  an  ulcerated  surface,  which  is 
moistened  by  an  adhesive,  serum-like  fluid.  The  affection  may 
appear  at  several  separate  points,  which,  pursuing  the  course 
mentioned,  may  fuse  together  and  occupy  a  large  portion  of  the 
cheek;  or  the  ulceration  may  spread  from  a  single  center.  Sim- 
ilar to  other  ulcers,  the  affected  surface  may  heal  centrally  while 
it  is  spreading  peripherally;  healing,  however,  is  rare,  unless  the 
case  be  properly  treated. 

The  tubercular  or  scrofulous  diathesis  obtains  in  the  subjects 
of  this  ulceration. 

Treatment. — The  cachexia  present  must  be  combated  by  appro- 
priate means:  iodine,  arsenic,  iron,  proper  food,  and  life  in  the 
open  air.  If  the  local  affection  be  yet  limited  to  a  small  point, 
it  may  be  removed  with  the  knife,  and  closure  by  suture  be 
effected;  to  accomplish  this,  however,  scrupulously  aseptic  work 
must  be  done,  else  the  operation  will  be  followed  by  a  tediously 
cicatrizing  wound.  And  even  despite  such  care,  failure  to  obtain 
immediate  union  so  often  occurs  that  the  writer  usually  follows 
another  treatment.  This  plan  was  only  arrived  at  after  trials  of 
other  methods ;  these,  in  the  main,  consisted  in  first  thoroughly 
curetting  the  diseased  surface,  and  then  applying  one  of  the  fol- 
lowing agents:  iodoform,  subiodide  of  bismuth,  powdered  rhu- 
barb or  ergot;  under  these  local  remedies,  such  a  diseased  surface 
may  heal,  yet  often  it  will  not  do  so.  A  better  method  was 
found  to  be  to  first  curette  the  part  thoroughly,  cauterize  the  bor- 
ders with  the  thermal  cautery,  and  then,  having  washed  with  a 
-20V0  solution  of  sublimate,  let  the  part  be  covered  with  gutta 
percha  tissue  paper.  And  tliis  dressing,  retained  in  place  by 
adhesive  plaster,  may  remain  unchanged  until  signs  of  suppura- 
tion show  themselves.  At  each  dressing  the  surface  should  bo 
washed  with  the  dilute  sublimated  solution.  Under  this  treat- 
ment the  author  has  succeeded  in  effecting  the  cure  of  an  obsti- 
nate example  of  the  affection  here  referred  to,  which  occupied  a 
large  part  of  the  right  cheek. 

As  remarked,  when  the  affection  is  limited,  it  may  be  treated 
by  excision,  yet  an  objection  to  this  plan  is  that  occasionally, 
instead  of  the  resulting  wound  healing  properly,  there  may 
develop  in  its  site  a  keloid  scar,  which  will  be  difficult  and  some- 
times imjDossible  to  eradicate. 

Parotidean  Region  of  the  Face. — Of  all  the  parts  which  lie 
within  the  region  of  the  face,  none  is  more  surgically  important 
than  the  parotidean  district;  hence,  an  accurate  knowledge  of 


510  MALAR    AND    TAROTIDEAX    KKGIOXS. 

tlie  region  is  so  necessary  to  the  surgeon  that  the  writer  finds  an 
excuse  for  the  extended  section  which  here  follows. 

The  parotidean  boundaries  vary  in  length  as  the  head  is 
extended  or  flexed,  and  in  breadth  according  to  the  movements 
of  the  lower  jaw.  Its  superficial  limits  are  the  following:  above, 
it  is  bounded  by  the  auditory  meatus  and  the  temporo-maxillary 
articulation;  in  front,  by  the  posterior  border  of  the  maxilla 
inferior;  beiiind,  by  the  anterior  border  of  the  sterno-cleido- 
mastoid  muscle  and  the  mastoid  process;  and  below  by  a  band  of 
fibrous  tissue,  which  is  connected  with  the  sterno-cleido-mastoid 
muscle  and  the  angle  of  the  lower  jaw. 

If  these  bounds  be  viewed  together,  they  form  an  oblong  fig- 
ure, of  which  the  horizontal  lines  are  much  the  shorter. 

The  gland  is  contained  in  a  fascial  envelope,  of  which  the  sides 
originate  and  are  arranged  as  follows:  The  aponeurotic  or  fascial 
sheath  of  the  sterno-cleido-mastoid  muscle,  after  reaching  the 
anterior  border  and  completely  enclosing  the  muscle,  divides  into 
an  anterior  and  a  posterior  layer.  Tiie  anterior  one  passes  in 
front  of  the  gland  and  fuses  with  the  masseteric  fascia.  The 
posterior  stratum  passes  behind  the  gland,  and  forms  a  wall 
between  it  and  contiguous  structures,  and  this  partition  is  imper- 
fect at  the  deepest  part,  where  the  gland  lies  near  the  wall  of  the 
pharynx.  This  internal  fascia  is  fastened  to  the  styloid  process, 
and  gives  off  processes  which  surround  the  muscles  which  are 
attached  to  that  process.  The  internal  or  deep  la3"er  of  fascia, 
after  reaching  the  anterior  border  of  the  gland,  fuses  with  the 
anterior  layer  of  fascia;  and  the  united  fascial  structure  passes 
forwards  and  covers  the  masseter  muscle.  Between  the  sterno- 
cleido-mastoid  and  the  parotidean  fascia  there  lies  a  mass  of 
tissue,  trilateral  in  form,  which  may  be  the  starting  point  of 
fibromatous  tumors  Mdiich  have  no  close  connection  with  the 
parotid  gland. 

If  the  fascial  wall  be  examined  in  respect  to  its  inferior  por- 
tion, it  will  be  found  complete  and  in  relation  with  the  fibrous 
band  which  extends  from  the  sterno-cleido-mastoid  to  the  man- 
dibular angle,  and  thus  the  wall  here  becomes  strongly  fortified. 
But  the  superior  part  of  the  wall  is  incomplete  where  the  gland 
adjoins  the  cartilaginous  portion  of  the  external  auditory  canal. 
The  parotid  gland,  there,  is  completely  isolated  from  the  sur- 
rounding structures  by  a  closely  fitting  fascial  wall,  except  at  its 
upper  part,  and  at  its  internal  or  deepest  part,  where  a  process 
like  the  end  of  a  finger  reaches  through  the  containing  fascia 


PAROTIDEAN    REGION    OP    THE    FACE.  511 

above  the  styloid  process  and  the  internal  carotid  artery.  Between 
the  deep  portion  of  the  gland  and  the  wall  of  the  pharynx  lie 
the  following  very  important  parts:  the  internal  carotid  artery, 
the  internal  jugular  vein,  the  pneumogastric  nerve,  the  spinal 
accessory,  the  glosso-pharyngeal,  the  hypoglossal,  and  the  sympa- 
thetic nerves, — parts  so  important  that  on  their  integrity  depends 
the  continuance  of  life.  The  anterior  border  of  the  gland  is 
molded  on  the  deep  and  superficial  faces  of  the  ramus  of  the  jaw  ; 
the  superficial  portion  is  continued  forwards  on  the  masseter 
muscle,  and  ends  in  the  duct  of  Steno,  its  outlet.  This  anterior 
process  is  sometimes  named  the  accessory  parotid. 

The  parotid  and  submaxillary  glands,  though  analogous  in 
being  racemiform  glands,  3'et  differ  greatly  in  respect  to  their 
fil)rous  stroma;  while  that  of  the  submaxillary  is  loose,  that  of 
the  parotid  is  compact,  dense  and  resistant.  And  this  unyield- 
ing stroma  interferes  with  swelling  of  the  parotid,  and  renders 
such  swelling  painful. 

Two  important  structures  traverse  the  parotid  gland:  the 
facial  nerve,  which  enters  the  deeper  portion  of  the  gland  and 
passes  transversely  through  it  and  divides  into  branches,  which 
pass  to  the  temple,  cheek,  and  lower  jaw;  the  other  structure  is 
the  external  carotid  artery,  which,  emerging  from  behind  the 
ramus  of  the  jaw,  at  the  union  of  the  lower  third  with  the  mid- 
dle third,  enters  the  gland.  This  vessel  enters  the  deep  portion 
of  the  gland  and  passes  thence  towards  its  surface ;  that  is,  after 
tlie  artery  enters  the  gland,  it  is  continuall}^  becoming  more 
superficial.  The  external  carotid,  while  it  lies  in  the  gland,  divides 
into  the  temporal  and  internal  maxillary  arteries;  and  these  ter- 
minal branches  lie  for  a  short  distance  in  the  upper  part  of  the 
parotid.  The  external  jugular  vein  lies  imbedded  in  the  gland. 
The  external  carotid  is  separated  from  the  internal  carotid  and 
the  nerve,  before  mentioned,  by  the  deep  fascia,  the  styloid  process 
and  the  styloidean  muscles;  hence,  in  case  of  the  tumor  invad- 
ing this  site,  the  styloid  process  becomes  a  signal-head  of  warning 
to  the  surgeon  against  penetrating  deeper  into  this  region, 
bristling  with  anatomical  perils. 

The  arteries  mentioned,  in  their  transit  through  the  gland, 
are  closely  adherent  to  the  fibrous  stroma  of  the  gland;  the  ves- 
sels lie  in  no  loose  sheath  b}^  which  they  may  be  separated  from 
the  gland,  so  that,  to  reach  them,  the  parotidean  structure  must 
be  literally  dug  out  or  removed  piecemeal.  The  facial  nerve,  on 
the  contrary,  is  so  loosely  attached  to  the  structure  which  it  trav- 


512  MALAR    AND    PAROTIDEAX    RKfilOXS. 

erses  that  it  can  be  dissected  out  in  the  normal  gland;  if  this, 
however,  is  diseased,  such  dissection  miglit  be  impossible. 

An  examination  of  the  gland,  proceeding  from  without 
inwards,  will  meet  successively  the  facial  nerve,  the  external 
jugular  vein,  the  external  carotid  arter}^  and  lymphatic  glands; 
the  glands  vary  in  number  and  position. 

The  anterior  prolongation  of  the  gland  lies  on  the  masseter 
muscle,  and  sometimes  reaches  to  its  anterior  border;  this  process, 
as  well  as  the  duct  which  continues  from  it,  lies  between  the  two 
fascial  la3'ers  before  mentioned,  which  extends  as  far  as  the 
point  where  the  duct  passes  into  the  buccinator  muscle.  The 
anterior  prolongation  of  the  gland  lies  in  a  line  on  the  masseter 
which  is  midway  between  the  zygomatic  arch  and  the  lower  bor- 
der of  the  maxilla  inferior.  This  prolongation  of  the  gland  is 
accompanied  by  the  transverse  facial  artery  and  branches  of  the 
facial  nerve. 

The  canal  of  outlet  of  the  parotid  gland,  named  the  Steno- 
nian  or  Stensonian  duct,  or  the  duct  of  Steno,  lies  deeper  than 
the  normal  subcutaneous  fascia,  and  has  an  outer  sheath  formed 
by  a  prolongation  of  the  parotidean  fascia;  and  within  this  outer 
sheath  there  is  another  which  surrounds  the  duct  directly  and 
lies  in  contact  with  it.  The  parotidean  excretory  canal  may  be 
divided  into  a  masseteric  and  buccal  portion,  which  lie  respect- 
ively on  the  masseter  and  buccinator  muscles. 

The  masseteric  portion  appears  as  a  white  cord,  a  line  and  a 
half  in  thickness;  and  from  its  beginning,  though  it  is  slightly 
curved,  it  pursues  its  course  forwards,  until,  reaching  the  ante- 
rior border  of  the  masseter,  it  is  bent  inwards,  almost  rectangu- 
larly, and  this  sudden  bend  is  an  obstacle  to  the  passage  of  a 
sound  into  the  canal.  The  canal,  finally  dropping  its  two  fibrous 
sheaths,  curves  suddenly  inwards,  and  opens  into  the  buccal  cav- 
ity opposite  the  first  upper  molar  tooth.  A  cutaneous  line  drawn 
from  the  aural  tragus  to  the  labial  commissure  overlies  the  parot- 
idean duct  (Tillaux).  Hyrtl  places  the  anterior  end  of  the  canal 
somewhat  higher;  according  to  him  tlje  duct  runs  in  a  line 
drawn  from  the  tragus  to  the  middle  of  the  naso- labial  sulcus. 
No  valves  exi.st  in  the  duct,  yet  the  sudden  infractions  which 
occur  at  two  points  are  obstacles  to  the  entrance  of  foreign  mate- 
rials. The  canal  is  about  sixteen  lines  long,  and  it  opens  into 
the  buccal  cavity  about  sixteen  lines  behind  the  angle  of  the 
mouth. 

The  excretory  canals  of  the   parotis  and   the  submaxillary 


PAROTITIS.  513 

gland  differ  in  regard  to  their  structure:  that  of  the  latter  is  soft 
and  analogous  to  that  of  a  vein,  while  the  parotidean  duct  is 
much  firmer,  and  has  been  compared  to  the  teiise  vas  def- 
erens. 

Inflammatory  Affections  of  the  Parotid  Gland:  Parotitis. — The 
leading  constituent  elements  of  the  parotid  gland  are  the  fibrous 
and  the  glandular;  Tillaux  claims,  in  opposition  to  most  author- 
ities, that  inflammation  of  the  gland  begins  in  the  fibrous  ele- 
ment; Virchow,  on  the  contrary,  teaches  that  the  inflammator}^ 
process  begins  in  the  glandular  element,  and  extends  thence  to 
the  adjacent  tissues. 

Virchow,  in  1859,  claimed  that  the  swelling  is  chiefly  located 
in  the  peri-glandular  tissues,  and  the  process  is  similar  to  that  of 
catarrhal  pneumonia,  prostatitis,  and  inflammation  of  the  middle 
ear.  The  inflamed  glandular  elements  are  red,  and,  in  the  com- 
mencement, yield  a  thin  catarrhal  excretion;  this  excretion  later 
becomes  purulent  in  nature.  In  the  pus,  one  finds  salivary  cor- 
puscles and  pus-cells.  In  severe  cases,  the  glandular  elements 
become  disintegrated  and  mingled  with  the  pus.  Virchow  found 
portions  of  the  gland  thus  destroyed,  while  the  intermediate  con- 
nective stroma  was  not  broken  down. 

The  parotis  has  the  same  relation  to  the  buccal  mucous  men: 
brane  as  the  prostate  gland  has  to  the  genito-urinary  mucous 
membrane. 

Pyaemia  may  result  from  such  inflammation,  and  this  may 
be  of  the  ichorrhgemic  or  of  the  embolic  or  metastatic  form. 

Virchow  and  Bamberger  divide  parotitis  into  three  classes: — 

1.  Primary  catarrh,  which  usually  occurs  epidemically;  this 
is  limited  to  a  simple  catarrhal  discharge,  with  no  tendency  to 
suppuration  or  ulceration. 

2.  Secondary  catarrh,  in  which  pus  and  abscess  appear,  and 
there  is  a  coexistent  oral  or  a|)hthous  affection,  or  disease  of  the 
middle  ear. 

3.  A  specific  catarrh,  almost  always  ending  in  an  ichorous 
discharge ;  and  this  is  commonly  associated  with  some  remote 
ichorrhsemic  or  embolic  metastasis. 

Causes  of  parotitis  are  erythema  or  catarrh  of  the  mouth ;  and 
the  weather  has  an  influence,  as  it  appears  oftenest  in  the  cold 
months  of  the  year. 

A  single  gland  may  be  affected,  yet  both  may  be,  and  then 
one  usually  precedes  the  other. 

As  events  of  parotitis  are  obstruction  and  swelling  of  the  veins 


")14  MALAR    AND    PAROTIDEAN    REGIONS. 

of  the  temple  and  cheek,  with  oedema.  The  liead  in  general,  and 
the  adjacent  eye  may  suffer.  From  retarded  movement  of  the 
blood  in  the  veins,  coagulation  can  occur;  and  such  clots  may 
decompose  and  become  ichorous.  Meantime,  the  contiguous 
lymphatics  and  glands  may  become  affected,  and  pus  can  form 
in  them. 

Besides  the  constituent  parts  of  the  parotis,  structures  adja- 
cent may  become  implicated:  viz.,  the  adjoining  muscles,  the 
middle  ear,  and  even  the  temporal  bones  and  the  subjacent  dura 
mater  may  become  affected.  And  in  the  worst  cases,  the  morbid 
process  passes  through  the  meninges  and  attacks  the  brain. 

The  diffusion  of  the  disease  is  by  continuity  and  contiguity: 
it  may  travel  along  nerve  trunks,  and  in  this  way  it  may  enter 
the  skull.  Another  route  for  intra-cranial  invasion  is  along  the 
veins  which  traverse  the  inferior  orbital  fissure ;  or  tlie  clotted 
material  may  pass  down  through  the  jugular  vein  to  the  lieart. 
Thus  the  inflamed  parotis,  ending  in  suppuration,  may  be  the 
source  of  morbific  materials,  which  may  awaken  disease  in  the 
brain,  heart  and  other  regions,  near  or  remote. 

There  is  an  increase  of  temperature  analogous  to  that  which 
accompanies  inflammatory  and  suppurative  action  elsewhere,  the 
range  of  temperature  being  proportionate  to  the  violence  and 
extent  of  these  processes. 

The  a[ioneurotic  envelope  and  the  unyielding  fibrous  stroma 
of  the  gland  impede  the  flow  of  blood  through  the  veins  and 
favor  coagulation.  The  same  constricting  tissues  tend  to  force 
out  pus  which  may  form  in  the  parotis. 

'  Su}»purative  parotitis  usually  falls  within  the  domain  of  sur- 
gery as  a  metastatic  j)y8emic  affection ;  and  often  it  is  a  secondary 
event  of  a  severe  wound  in  some  other  part  of  the  body ;  its 
appearance  should  excite  grave  apprehension. 

Treatment. — From  the  facts  presented,  it  is  clear  that  suppura- 
tive parotitis  is  an  affection  which  may  imperil  and  sometimes 
destroy  life;  and,  hence,  its  treatment  should  be  prompt  and  ener- 
getic ;  the  milder  grades  of  parotitis,  however,  seldom  demand 
attention  on  the  part  of  the  surgeon.  Where  the  evidences  of  pus 
are  presented,  as  denoted  by  local  tumefaction,  increased  heat  and 
general  rigor,  an  incision  should  be  made  so  that  the  pus  impris- 
oned within  the  unyielding  fascia  may  have  free  escape.  Since 
the  most  accurate  anatomical  knowledge  cannot  locate  the  vessels 
and  nerves  of  the  gland  with  absolute  accuracy,  the  opening 
should  be  made  in  stich  a  manner  as  to  give  these  structures  the 


PAROTIDEAN    GROWTHS.  515 

greatest  safety;  and  for  this  purpose,  the  incision  with  the  scalpel 
should  not  penetrate  beyond  the  superficial  fascia;  and  then  the 
opening  should  be  continued  by  means  of  a  blunt  dissector,  or  a 
small  pair  of  dressing  forceps,  which,  being  thrust  in,  may  be 
opened  and  withdrawn  as  Hilton  directs,  so  as  to  make  a  free 
opening.  Thus  the  pus  may  be  reached,  and  any  vessel  or  nerve 
which  might  be  met  will  be  displaced,  and  not  seriously  injured. 
As  two  or  more  separate  pus-centers  may  coexist,  each  of  these 
may  be  opened  in  a  similar  manner.  Thus,  by  prompt  and  early 
action,  the  suppurative  process  may  be  arrested.  The  openings 
made  are  slow  in  healing;  a  serum-like  fluid  may  exude  from 
the  wounds  for  a  long  period.  This  material  contains  saliva, 
which  is  derived  from  the  wounded  glandular  structure.  If  none 
of  the  larger  secondary  ducts  of  the  parotis  be  opened,  the  wounds 
under  proper  treatment  will  finally  heal. 

Parotidean  Growths. — The  parotid  gland,  comj^licated  as  are  its 
structural  constituents,  is  suited  by  nature  to  be  tlie  natal  site  of 
numerous  neoplasms ;  every  species  of  growth,  from  the  simple 
cyst  to  the  gravest  types  of  malignant  tumor,  occurs  here;  and, 
beginning  with  the  simplest,  cystoma  first  offers  itself  for  con- 
sideration. 

As  varieties  of  cyst,  the  following  have  been  observed  here: 
the  sebaceous  cyst,  the  simple  serous  cyst,  the  salivary  cyst,  and 
cysts  in  which  two  or  m.ore  species  are  associated. 

The  cyst  of  sebaceous  or  atheromatous  content  occurs  in  this 
region.  It  belongs  rather  to  the  derm  than  to  the  gland.  It  is 
usually  small,  though  the  writer  has  removed  one  of  rounded 
form,  of  which  the  diameter  exceeded  two  inches.  Such  sebaceous 
tumor  causes  but  little  functional  disturbance;  as  a  deformity, 
however,  its  removal  is  indicated.  This  may  be  done  by  a  hori- 
zontal or  vertical  cut  through  the  skin  and  the  filamentous  cap- 
sular envelope  of  the  cyst.  The  only  structures  which  might  be 
endangered  in  this  enucleation  are  branches  of  the  facial  nerve. 
But  as  these  nerve  filaments  are  beneath  the  fascial  envelope  of 
the  gland,  which  structure  intervenes  as  a  well-defined  septum 
between  the  cyst  and  the  nerves,  the  latter  could  .only  be  wounded 
through  careless  dissection.  If  the  wall  of  the  cyst  be  well  exposed 
through  a  horizontal  cut,  the  growth  can  be  enucleated  from  the 
lateral  and  subjacent  structures  b}^  means  of  a  blunt  dissector. 
And  if  the  proper  parotidean  fascia  be  left  intact,  the  branches  of 
the  facial  nerve  will  not  be  wounded. 

The  cyst  of  purely  serous  content  has  been  observed  in  a  few 


516  MALAR    AND    PAKOTIDEAN    KECilOXS. 

cases  in  the  purotidean  region.  The  contained  iiuid  has  none  of 
the  reactions  of  saliva.  This  cyst  may  be  disposed  ol"  by  excision  ; 
but  before  resorting  to  the  knife,  an  effort  to  cure  should  be  made 
by  injecting  the  cyst  with  the  tincture  of  iodine. 

A  cyst  similar  to  the  one  just  mentioned,  is  that  in  which  the 
content  is  salivary;  such  a  cyst,  of  small  or  large  dimensions,  may 
arise  from  the  retention  of  saliva  in  one  of  the  ducts  which  con- 
vey the  secretion  from  a  lobule  of  the  parotis.  This  cyst  resem- 
bles that  of  purely  serous  character;  yet  the  two  can  be  distin- 
guished from  each  other  b}''  the  fact  that  that  of  salivary  content 
yields  the  characteristic  reaction  of  saliva,  viz.,  it  converts  starch 
into  grape  sugar.  The  salivar^^  cyst  is  diflicult  to  cure.  Two 
modes  of  treatment  liave  been  advised;  in  one  there  is  established 
a  communication  between  the  cyst  and  the  buccal  cavity;  in  the 
second  plan  there  is  an  effort  made  to  destroy  the  walls  of  the 
cyst,  and  thus  through  suppuration  to  obliterate  the  cystic  cavity. 
Such  destructive  action  with  subsequent  obliteration  may,  some- 
times, be  accomplished  by  cauterizing  the  cavity  thermally  or 
potentially.  As  a  potential  escharotic,  one  might  use  the  sulphate 
of  zinc,  with  which,  in  small  crystalline  form,  the  cystic  cavity 
may  be  filled.  Thus  the  inner  wall  is  destroyed  and  an  action  is 
set  up  in  the  subjacent  tissues  which  may  end  in  obliteration  of 
the  salivary  cyst. 

Salivary  Concretion. — The  calcareous  salivary  concretion  named 
sialolith,  frequently  observed  in  connection  with  the  submaxillary 
gland,  has  also  been  seen,  though  seldom,  in  the  parotis.  The 
source  of  this  calculus  is  the  mineral  constituent  of  the  saliva; 
and  this  consists,  in  the  main,  of  phosphate  and  carbonate  of 
lime.  IIow  the  initial  nucleus  begins,  since  it  is  not  seen,  has, 
like  vesical  calculus,  been  rather  a  matter  of  conjecture  than  of 
actual  proof. 

The  sialolith  has  been  a  matter  of  study  by  Immisch,  who  in 
his  publication  in  1861  classifies  these  concretions  in  those  which 
lie  in  the  gland,  and  those  occurring  in  the  excretory  canal  of  the 
gland.  As  assignable  cause  of  such  formation,  Immisch  thinks 
the  starting  j3oint  may  be  a  chronic  inflammation  in  a  duct, 
whence  arise  elevations  and  depressions  of  the  surface.  In  this 
way  the  outflow  of  saliva  is  impeded  and  from  the  retained  fluid 
precipitation  may  occur.  And  the  concrete  material  may  close 
the  duct;  or  it  may  form  in  such  a  manner  as  to  leave  an  open- 
ing through  which  the  saliva,  which  is  scretod  behind,  may  still 
find  escape. 


ANGIOMA.  617 

A  possible  method  in  which  the  sialolith  may  form  is  about  a 
body  which  has  penetrated  and  lodged  in  the  gland.  Possibly, 
such  foreign  body  might  penetrate  the  common  duct  from  the 
buccal  cavity. 

The  most  usual  site  of  such  concretion  is  the  duct  of  Wharton ; 
it  rarely  forms  in  the  duct  of  Steno,  and  most  rarely,  if  ever,  in 
the  sublingual  duct.  The  facility  of  escape  of  the  secretion  from 
the  parotis  and  sublingual  glands  may  account  for  the  infrequency 
of  the  sialolith  in  these  glands. 

The  sialolith  is  seldom  seen  in  the  young;  it  has  been  seen 
oftenest  in  those  between  thirty  and  forty  years  of  age.  It  is 
usually  rounded  or  amygdaloid  in  form. 

The  sialolith  may  remain  for  a  long  time  without  causing 
much  disturbance;  finally,  by  encroaching  on  parts  contiguous, 
it  awakens  inflammation,  and  finally  pus  is  formed.  If  in  the 
common  excretory  canal,  it  can,  by  impeding  the  escape  of  saliva, 
cause  much  more  trouble  than  if  lodged  in  the  structure  of  the 
parotis. 

Since  the  tumefaction  caused  by  the  concretion  might  arise 
from  other  growths,  a  differential  diagnosis  is  best  made  by 
means  of  a  fine  acupuncture  needle.  In  a  few  cases  recorded  of 
parotidean  sialolith,  the  true  nature  of  the  affection  has  been 
revealed  by  an  opening  occurring  spontaneously,  or  made  by  the 
surgeon,  through  the  outer  surface  of  the  cheek,  through  which 
the  calculus  could  be  seen  or  touched  with  a  probe. 

Treatment. — The  calculus  should  be  removed,  and,  to  avoid  a 
salivary  fistula,  the  opening,  as  a  rule,  should  be  made  to  the  site 
of  the  concretion  on  the  inner  side  of  the  cheek.  This  may  be 
done  by  slitting  up  the  buccal  ending  of  the  Stenonian  duct,  as 
Manec  has  advised;  or  the  opening  may  be  made  directly  to  the 
calculus  from  the  inside  of  the  mouth.  In  the  event  of  there 
being  an  opening  to  the  body  from  the  outside,  as  not  unfre- 
quently  is  the  case  when  the  patient  first  comes  under  observa- 
tion, this  opening  should  be  enlarged,  and  the  calculus  thus 
extracted.  From  the  report  of  cases  treated  in  the  latter  way,  it 
would  seem  that  no  salivary  fistula  remained  afterwards. 

Benign  Tumors. — The  class  of  benign  tumors  is  well  represented 
in  the  parotidean  region;  the  angioma,  lipoma,  fibroma,  adenoma 
and  chondroma  occur  in  the  parotidean  region,  each  of  these 
arising  from  a  normal  anatomical  element  of  the  gland. 

Angiovia. — The  angioma  here  may  be  dermal  in  site  and 
present  itself  in  different  grades;  and  such  dermal  growth  may 


518  MALAR    AND    PAKOTIDEAN    KEGIOXS. 

be  treated  in  accordance  with  methods  which  have  previously 
been  exphiined. 

Angioma  involving  the  structure  of  the  parotis  is  a  much 
more  formidable  affection  than  tliat  of  dermal  site.  This  form  is 
congenital,  and  at  the  birth  of  the  child,  it  may  be  voluminous 
and  occupy  the  entire  gland.  Such  tumor  is  cavernous  in  struc- 
ture, yielding  to  pressure,  and  variable,  somewhat,  in  volume, 
viz.,  it  has  the  character  of  erectile  tissue,  and  is  swollen  during 
expiratory  efforts  of  the  child.  The  overhanging  skin,  without 
participating  in  the  vascular  growth,  may  show  some  widening 
of  its  capillaries,  and  through  the  skin  the  bluish  red  color  of  the 
subjacent  vascular  structure  may  be  perceived.  The  growth 
arises  from  abnormal  develoi)ment  of  the  normal  veins  and 
arterioles;  the  veins  in  number  and  volume  exceed  greatly  the 
arterioles.     These  widened  veins  present  cavern-like  dilatations. 

The  author  has  treated  three  cases  of  [)arotidean  angioma; 
two  were  in  children  five  and  eight  weeks  of  age,  respectively, 
and  the  third  in  an  adult,  in  whom  the  affection  was  present  at 
birth,  and,  besides  involving  the  parotid  gland,  it  involved  the 
subcutaneous  soft  parts  of  the  right  cheek  from  the  zygomatic 
arch  to  the  lower  border  of  the  maxilla  inferior.  This  patient 
had  a  frequently  recurring  spasmodic  m.ovement  of  the  facial 
muscles  on  the  affected  side,  a  movement  resembling  that  induced 
in  muscles  by  the  Faradic  electric  current.  The  posterior  por- 
tion of  the  gland  in  the  adult  case  was  not  affected,  but  in  the 
two  infants  the  entire  parotis  was  occupied  by  the  growth. 
Besides,  in  one  infant,  the  vascular  tumor  reached  below  the 
lower  jaw,  and  embraced  also  the  adjacent  submaxillary  gland. 
In  each  case  the  angioma  was  a  marked  deformity,  for  which 
relief  was  sought  at  the  hands  of  the  surgeon. 

Treatment. — The  treatment,  most  usually  resorted  to,  has  been 
removal  of  the  tumor  by  excision.  In  the  adult  seen  by  the 
writer,  there  had  been  made  an  effort  in  infancy  to  obliterate  the 
structure  by  subcutaneous  strangulation,  which  was  done  by 
means  of  long  needles,  w^hich  pierced  the  growth  deeply,  and 
then  the  outer  ends  of  the  needles  were  included  in  twisted 
suture.  The  result  obtained  was  only  a  partial  success;  and  the 
portions  wliich  remained,  developed  so  as  to  greatly  deform  that 
side  of  the  face.  For  relief  of  this,  the  patient  was  operated  on 
by  the  writer,  as  follows:  A  crescentic  or  rather  a  paraboloid  cut 
was  made  througli  tVie  skin,  which,  beginning  at  the  malar  bone, 
extended  towards  the  angle  of  the  mouth,  and  thence  passed 


ANGIOMA.  519 

downwards  and  backwards  to  the  lower  edge  of  the  maxilla 
inferior,  vertically  beneath  the  point  of  beginning.  This  flap 
being  reflected  and  drawn  well  backwards,  a  large  part  of  the 
vascular  growth  was  exposed.  This  was  found  to  involve  the 
anterior  portion  of  the  parotis,  and  to  extend  along  and  beyond 
the  Stenonian  duct  almost  to  the  angle  of  the  mouth.  The  fatty 
mass  around  the  terminal  end  of  the  duct  had  undergone  the 
vascular  transformation.  The  removal  of  the  angiomatous 
structure  was  done  piecemeal ;  this  was  the  only  way  in  which  it 
could  be  done,  since  the  remaining  cicatricial  adhesions  of  the 
former  operation  prevented  any  attempt  at  removal  in  mass. 
The  flap  was  closed,  yet,  owing  to  secondary  haemorrhage,  the 
internal  wound  was  tedious  in  healing.  The  face  was  much 
improved  in  appearance;  and  the  choreic  movement,  already 
mentioned,  of  the  risorius  Santorini  and  zygomatic  muscles  of 
the  face  on  that  side  which  had  harassed  the  patient  greatly, 
disappeared  after  the  operation. 

In  the  two  infants  the  treatment  pursued  was  excision.  In 
one,  a  portion  of  the  parotid  gland  and  of  the  submaxillary 
gland  was  extirpated.  The  result  obtained  was  that  the  young 
patient  was  delivered  of  the  tumor,  but  there  remained  perma- 
nent palsy  of  the  muscles  of  the  lower  half  of  the  face.  Twenty 
years  afterwards,  when  the  young  woman  was  seen,  it  was  gravely 
questionable  with  the  author  whether  the  chagrin  entailed  by 
the  operation  was  not  greater  than  that  which  would  have  arisen 
from  the  unoperated  tumor.  In  the  second  infant,  under  two 
months  of  age,  a  large  cuneiform  section  was  excised  from  the 
tumor,  and  the  wound  was  closed  by  deeply  including  sutures. 
This  child  surviA^ed  the  operation  only  a  few  days.  Hence  excis- 
ion of  the  congenital  parotidean  angioma,  advised  by  general 
authority,  from  the  results  obtained  by  the  author  in  the  two 
cases  mentioned,  was  unsatisfactory.  In  such  a  case,  subcutaneous 
thermal  cauterization  might  be  essayed  with  the  hope  of  better 
results.  This  may  be  done  by  means  of  a  long  needle,  which, 
being  inserted  one-half  its  length,  the  external  portion  may  be 
heated  by  means  of  a  spirit  lamp  in  the  manner  already 
described.  This  cauterization  should  be  done  in  horizontal  lines 
so  placed  as  to  avoid  the  parotidean  duct.  If  cauterization  were 
thus  done,  there  would  be  less  risk  of  injuring  the  branches  of 
the  facial  nerve. 

Another  plan  of  treatment  which  might  be  tried  is  continued 
pressure  maintained  on  the  angiomatous  tumor.     For  this  pur- 


520  MALAR    AND    PAHOTIDKAX    KlXilONS. 

pose  a  disk  of  India  rubber  might  be  retained  on  the  tumor  by 
means  of  an  ehistic  bandage.  To  accomplish  much,  such  com- 
pression should  be  continued  for  several  montlis. 

Lipoma  in  this  region  may  be  situated  merely  beneath  the 
skin,  or  it  maybe  imbedded  in  the  ghmd.  The  only  appro})riate 
treatment  is  extirpation  of  tlie  growth. 

The  fibroma  occurs  in  the  j)arotis;  an  example  of  this  was 
seen  by  tlie  writer.  In  its  extreme  hardness,  this  growth  resem- 
bles carcinoma;  the  fibroma,  however,  may  be  distinguished 
from  carcinoma  in  this,  that  the  latter  continues  to  develop  with- 
out limit,  while  fibroma  grows  more  slowly,  and,  liaving  reached 
a  certain  volume,  it  may  not  become  larger.  It  is  claimed  that 
fibroma  under  the  influence  of  some  inflammatory  agency  may 
become  malignant.  The  proper  treatment  of  tlie  parotidean 
fibroma  is  removal  through  a  horizontal  incision. 

The  lymphatic  glands,  which  lie  on  the  parotis,  or  imbedded 
in  its  structure,  may  inflame,  suppurate  and  open  through  the 
skin.  A  slowly  healing  sinus  may  thus  arise.  Such  cases  should 
be  treated  by  curetting  tlie  alfccted  structure  and  dressing  the 
wound  with  an  ointment  of  iodoform  or  of  subiodide  of  bismuth. 

Lymphatic  glands,  here  situated  in  the  scrofulous  subject,  may 
enlarge  and  remain  so  without  suppurating.  The  application  of 
iodized  collodion  often  reduces  such;  if  this  fails,  the  glands  may 
be  excised  through  a  horizontal  incision.  In  the  lower  portion 
of  the  parotidean  region  such  enlarged  glands  are  often  seated  so 
deep  that,  in  their  excision,  the  filament  of  the  facial  nerve  which 
passes  behind,  and  close  to,  the  mandibular  angle  may  be  injured, 
unless  the  operator  seeks  for  and  isolates  the  nerve.  If  such 
filament  be  injured,  the  lower  lip  and  angle  of  the  mouth  will  be 
disturbed  in  their  movements. 

Enchondroma  lias  been  observed  in  the  parotis;  and  this  may 
be  associated  with  fibroma;  and  it  is  probable  that  enchondroma 
here  is  tlie  offspring,  or  successor,  of  fibromatous  structure.  The 
cartilaginous  tumor  may  be  removed  through  a  horizontal  cut. 

Busch,  in  a  study  of  the  benign  tumors  which  develop  in  the 
parotis,  finds  that  they  most  ordinarily  appear  in  the  inferior 
part  of  the  region,  viz.,  in  that  which  lies  between  the  mastoid 
process  and  the  angle  of  the  jaw.  In  this  site  the  cartilaginous 
tumor  is  oftenest  found  bound  tightly  down  by  the  parotidean 
fascia.  Being  thus  tightly  bound  down  by  this  dense  fascial 
stratum,  as  soon  as  the  latter  is  opened,  tlie  tumor  rises  through 
the  gap  made,  so  that  enucleation  is  facilitated. 


MALIGNANT    GROWTHS    OF    THE    PAROTID    GLAND.  521 

Where  the  tumor  is  from  the  degeneration  of  one  or  more 
lymphatic  glands,  it  lies  outside  of  the  fascial  covering  of  the 
parotis;  and  in  this  site  it  is  movable  under  the  skin. 

Busch  finds  that  in  partial  removal  of  the  parotis,  the  result- 
ant palsy  will  depend  on  the  part  of  the  gland  which  is  extirpated. 
For  example,  in  excising  the  lower  portion,  nervous  filaments  to 
the  neck  will  be  severed;  if  the  middle  portion  be  excised,  fila- 
ments to  the  mouth  will  be  injured;  and,  finally,  if  the  upper 
portion  of  the  parotis  be  removed,  the  nervous  filaments  to  the 
eyelid  will  be  cut.  Allied  to  the  benign  growths  described  may 
be  mentioned  the  syphilitic  affection  of  the  lymphatic  glands 
here  situated,  which  may  become  infected  and  swell  in  case  of 
primary  chancrous  ulcer  having  its  site  in  the  lips  or  mouth. 
Care  must  be  taken  not  to  confound  such  disease  with  that  which 
might  arise  from  tubercular  disease.  When  the  syphilitic  nature 
of  the  case  has  been  diagnosticated,  the  treatment  should  be  simi- 
lar to  that  of  constitutional  syphilis. 

In  case  ptyalism  supervenes  during  mercurial  treatment,  the 
parotid  gland  swells;  and  the  accessory  portion  of  the  gland  may 
swell  as  a  small  isolated  tumor  in  the  cheek.  Such  tumefaction 
would  gradually  vanish  with  the  subsidence  of  the  salivation. 

Malignant  Groivths  of  the  Parotid  Gland. — Sarcoma  is  a  fre- 
quent occupant  of  the  parotidean  region;  and  the  growth  pre- 
sents itself  here,  as  elsewhere,  in  its  diversified  form,  viz.,  as 
fasciculated,  encephaloid,  myxomatous  and  cystic  sarcoma. 

The  most  common  form  is  the  fasciculated  type,  which,  appear- 
ing in  circumscribed  form,  is,  at  first,  firm  and  solid  in  texture; 
and  later,  as  it  attains  larger  volume,  it  is  lobulated,  softer  and 
rich  in  ve'ssels.  The  microscope  reveals  elongated  and  spindle- 
shaped  cells.  And,  imbedded  in  the  same  structure,  one  finds 
proliferated  or  multiplied  epithelial  cells.  Sarcoma,  in  its  subtle 
and  shifting  morphology,  sometimes  bafiies  definite  classification, 
and  escapes  from  the  well-built  bounds  of  the  descriptive  histolo- 
gist.  Thus,  as  just  stated,  sarcomatous  structure  is  commingled 
with  degenerated  epithelial  elements,  which  are  of  the  nature  of 
epithelioma ;  also,  cystic  dilatations  are  often  found  in  the  sarcoma, 
arising  from  the  dilated  cul-de-sacs  of  the  initial  glandular  ducts. 
The  encephaloid  species  of  sarcoma,  constituted  of  round  cells, 
is  soft  in  consistence,  and  develops  rapidly,  and  often  contains 
dilated  ducts  and  degenerated  epithelium.  Akin  to  encephaloid 
sarcoma  is  the  melanotic  tumor,  which  has  been  seen  here  by 

Weber. 

34 


522  MALAR    AND    PAROTIDEAN    REGIONS. 

The  cystic  dilatations  may  contain  material  similar  to  lique- 
fied gelatine;  and  a  tumor  thus  formed  is  named  myxomatous 
sarcoma.  This  tliickened,  jelly-like  content  is  a  i)roduct  of  the 
glanduhir  structure,  that  has  wandered  quite  away  from  its  pre- 
destined function  of  secreting  saliva.  The  cyst,  containing 
sarcoma,  is  nodulated  in  its  form. 

The  sarcomatous  parotidean  tumor  appears  in  the  youthful 
subject,  or  in  those  who  have  not  reached  the  declining  period  of 
life.  It  is  so  painless  in  its  advent  that  it  may  liave  attained 
some  size  when  it  is  accidentally  discovered,  as  an  eminence 
causing  irregularity  of  surface  of  tliat  portion  of  the  face.  The 
sarconja  is  not  inclined  to  become  generalized;  and  this  character- 
istic of  isolated  action  renders  the  tumor  a  more  [)r()per  one  for 
extirpation  than  is  the  case  in  carcinoma.  Leading  authority 
favors  the  removal  of  the  sarcomatous  neoplasnj ;  and  in  the  event 
of  there  being  a  recurrence,  a  second  or  third  operation  has  some- 
times been  successful  in  curing  the  patient. 

Epithelioma,  primarily  arising  in  the  parotis,  has  been  the 
matter  of  discussion  among  pathologists;  some  doubt  whether 
tliis  growtli  in  pure  form  arises  in  the  parotis.  0.  Weber  claims 
the  case  to  be  epithelioma  when  the  degenerated  acini  of  the 
gland  have  lost  their  limiting  membrane,  and  the  multiplied 
epithelial  cells  encroach  on  the  interstitial  structure. 

Delorme  prefers  the  name  epithelial  adenoma  for  these 
growths;  and  as  anatomical  characteristics  Delorme  enumerates 
the  following:  in  form  it  is  spherical,  ovoid,  nodulated  or  regular 
in  outline;  in  consistence  it  is  soft  or  elastic,  and  is  definitely 
separated  from  adjacent  structures,  and  is  rarely  accompanied  by 
facial  palsy.  The  tumor  has  commonly  been  observed  in  tlie 
youthful  subject.  If  ulceration  occurs,  the  process  is  similar  to 
that  seen  in  the  non-malignant  tumor.  There  is  rarely  glan- 
dular infection,  and  the  general  health  is  seldom  depressed.  On 
section  the  tumor  presents  a  granular  a.spect;  and,  if  the  jiart 
be  compressed,  cylindrical  bodies  resembling  vermicelli  will  be 
forced  from  the  incised  surface.  Under  the  niicroscoi»e  a  com- 
plex structure  ai)pears,  in  which  fibrous,  cartilaoinous  and 
myxomatous  tissues  are  seen;  also  epithelial  cells  dispersed  in 
cylindrical  or  bird-nest  form. 

Epithelioina. — Epithelioma  may  commence  primarily  in  the 
parotis,  or  it  may  appear  there  secondarily,  viz.,  in  a  lymphatic 
gland,  the  disease  appearing  metastatically  in  the  gland  from  an 
epithelioma  seated  in  the  eye,  the  cheek,  the  lip  or  tlie  mucous 


CARCINOMA.  523 

membrane  of  the  buccal  or  pharyngeal  cavity.  Also  an  epithe- 
lioma, which  has  originated  in  the  dermal  glands  overlying  the 
parotis,  may  penetrate  through  the  skin  and  attack  the  gland. 

Carcinoma. — Cancerous  disease  may  appear  in  the  hard  and 
soft  forms,  that  is,  as  scirrhous  and  encephaloid  cancer.  The 
disease  may  appear  here  as  an  aboriginal  product;  or  it  may 
migrate  to  the  parotis  from  a  neighboring  part  where  it  first 
appeared. 

These  two  forms  of  carcinoma  differ  radically  from  each  other 
in  structure.  Scn-rhus  is  firm,  of  wood-like  hardness,  is  intimately 
adherent  to  the  contiguous  parotidean  structure,  and  the  boundary 
between  it  and  the  unaffected  glandular  structure  is  scarcely 
discoverable.  On  the  contrary,  the  encephaloid  growth  has  a 
more  definite  boundary;  it  is  both  soft  and  elastic,  and,  examined 
microscopically,  encephaloid  cancer  presents  a  fibrous  stroma,  in 
tlie  meshes  of  which  are  found  fluid  and  cells  of  variable  form. 
Both  forms,  besides  implicating  the  gland,  sooner  or  later  be- 
come adherent  to  the  skin  and  cause  puckering  of  surface,  espe- 
cially so  in  the  case  of  the  scirrhous  form.  These  growths  have 
no  tendency  to  limitation,  but  sooner  or  later  invade  and  press  on 
adjacent  parts;  and  in  this  way  grave  functional  disturbance  is 
caused.  Thus  mastication  is  rendered  difficult  through  pressure 
on  the  muscles  concerned  in  that  act;  also,  thus  may  arise  palsy 
and  pain  in  the  region  of  the  face.  The  growth  may  compress 
vessels,  or  even  penetrate  them.  The  overlying  skin  is  finally 
perforated  by  ulceration,  and  exuberant  and  vascular  granulations 
protrude  through  the  breach.  The  pus  excreted  is  of  foul  odor. 
In  from  six  to  twenty-four  months  the  patient  dies;  and  death 
may  arise  from  exhaustion  induced  by  diffusion  and  migration 
of  the  disease  to  important  viscera,  as  the  lungs  or  brain;  also, 
through  ulceration,  vessels  may  be  opened  and  recurring  haemor- 
rhages ensue.  Hence  the  prognosis  of  carcinoma  of  the  j^arotis 
is  highly  unfavorable. 

Melanotic  cancer  has  been  observed  here,  and  is  remarkable 
for  its  rapid  progress,  speedy  recurrence  after  extirpation,  and 
early  fatal  termination. 

Pile  accessory  parotid  gland  seated  on  the  Stenonian  duct  has 
been  the  site  of  neoj)lastic  formations  similar  to  those  which 
appear  in  the  parotid  gland  itself. 

Treatment  of  Malignant  Tumors  of  the  Parotis. — This  treatment 
has  been  the  matter  of  sharp  controversy,  some  espousing  the 
side  of  non-interference  in  case  the  tumor  has  attained  large 


524  MALAR    AND    PAROTIDEAX    KEdlONS. 

dimensions  and  occupies  a  large  part  of  the  parotis;  others,  again, 
ardently  contend  that  the  affected  gland  should  be  removed. 
Topographical  anatomists  have  taught  that  it  is  extremely  diffi- 
cult to  remove  the  parotis  in  the  cadaver;  and  they  liave  argued, 
from  this,  the  impossibility  of  such  removal  when  the  gland  is 
degenerated  or  changed  through  disease.  Says  Hyrtl:  "It  is  well 
known  to  the  anatomist  how  difficult  it  is  to  dissect  out  the  sound 
parotis  without  leaving  fragments  of  it  behind;  what  is,  then,  to 
be  expected  in  the  attempt  when  the  parotis  is  dissected?  Truly, 
says  one  of  the  leading  French  authorities,  the  extirjmtion  of  the 
diseased  gland  is  an  operation  quite  impossible."  Allan  Burns  said, 
in  his  "Surgical  Anatomy  of  the  Head  and  Neck,"  in  1811:  "The 
extirpation  of  the  gland  is  quite  out  of  the  question;  its  imprac- 
ticability is  proved  by  reviewing  the  connections  of  the  gland. 
"Whoever  has  in  situ  injected  the  salivary  duct  with  mercury', 
and  then,  even  when  the  gland  is  healthy,  where  it  was  free  from 
preternatural  adhesions,  and  limited  to  its  natural  size,  has  tried 
to  cut  it  out,  would  be  convinced,  when  he  saw  the  mercury 
running  from  the  innumerable  pores,  that  the  gland  extends  into 
recesses  into  which  he  could  not  trace  it  in  the  living  body.  .  .  . 
On  the  dead  subject  I  have  attempted  the  extirpation  of  such 
tumors,  but,  even  there,  have  never  succeeded  in  clearing  fully 
away  the  diseased  substance." 

Such  teaching  deterred  many  from  operating;  a  few  surgeons 
disregarded  the  edict  of  the  anatomist,  and  in  1841  Berard  pub- 
lished a  work  on  the  subject  in  which  were  reported  fifty-two 
extirpations  of  the  parotid  gland.  Berard  finds  that  the  removal 
of  the  parotis  is  not  more  perilous  than  other  capital  operations; 
for  of  the  fifty-two  cases  no  one  died  during  the  operation;  and 
in  only  two  or  three  cases  did  death  supervene  two  or  three  days 
afterwards.  And  he  claims  that  it  is  no  longer  a  question 
whether  the  parotis  can  be  extirpated,  but  rather  whether  the 
disease  can  be  entirely  removed  from  the  cavity  occupied  by  tlie 
diseased  gland.  Bruns  has  collected  a  much  larger  list  of  extir- 
pations of  the  parotis,  which  shows  that  the  operation  is  practi- 
cable, and  not  especially  perilous;  wdiere  death  occurred  it  was 
from  some  extrinsic  comi)lication. 

Extirpation  of  the  })arotis  endangers  the  external  carotid 
artery,  the  internal  jugular  vein  and  the  facial  nerve.  Strangely 
enough,  some  claim  to  have  removed  the  gland  and  to  have  left 
the  artery  and  nerve  intact.  Malgaigne  declared  in  1858  that 
the  parotis  can  be  removed  without  lesion  of  these  parts.     Burns 


CARCINOMA.  525 

denies  the  possibility  of  this,  and  claims  that  such  extirpation 
has  only  been  the  removal  of  a  conglobate  gland,  of  which  there 
are  two  in  connection  with  the  parotis:  one  in  the  center  of  the 
parotis  near  the  division  of  the  external  carotid,  and  one  division 
underneath  its  lower  lobe.  In  proof  of  this,  he  cites  cases  which 
he  saw  operated  on;  and,  in  the  discussion  of  the  subject.  Burns 
gives  glimpses  of  professional  rivalry  which  animated  both  pen 
and  scalpel  in  his  day. 

To  guard  against  hsemorrhage,  the  primitive  carotid  has  been 
tied,  likewise  the  external  carotid;  or,  instead  of  directly  tying 
the  vessel,  some  have  used  a  provisional  ligature;  that  is,  a  cord 
has  been  passed  underneath  the  artery,  and  afterwards  tied,  if 
the  vessel  was  opened.  Others  have  depended  on  compression 
made  by  the  hands  of  a  competent  assistant.  Each  of  these  plans 
has  had  advocates  of  its  superiority.  The  ligation  of  the  external 
carotid,  and  not  the  primary  trunk,  is  the  preferable  plan ;  and  in 
whichever  way  it  is  done,  blood  by  reflux  soon  finds  its  way 
through  the  ocular  branches  of  the  internal  carotid  into  those  of 
the  external  carotid  artery;  but  this  vascular  compensation  occurs 
sooner  when  the  external  and  not  the  common  carotid  is  ligated, 
since  the  blood  in  the  internal  trunk  is  then  subjected  to  more 
pressure.  In  case  the  extirpation  of  the  parotid  be  but  partially 
done,  or  if  the  growth  be  capsulated,  and  hence  so  isolated  that 
it  may  be  removed  without  removing  the  gland  itself,  then  the 
hsemostasis  may  be  accomplished  by  indirect  compression,  that  is, 
by  pressure  on  the  primitive  trunk,  or,  better  yet,  by  pressure  at 
the  bifurcation  of  the  common  trunk. 

The  entire  extirpation  cannot  be  effected  without  lesion  of  the 
external  carotid,  though  some  have  asseverated  to  the  contrary. 
And  the  same  is  true  of  the  facial  nerve;  its  branches  will  be 
severed,  and  the  face  palsied  on  that  side.  And  of  this  condition, 
to  which  the  operation  invariably  consigns  the  patient,  he  should 
be  plainly  foretold.  The  mouth  will  be  drawn  to  the  opposite 
side;  the  emotional  movements  will  be  lost  on  the  side  operated 
on;  the  movement  of  the  corresponding  eyelids  is  lost,  so  that  the 
eye  will  remain  staringly  open,  and,  as  the  result  of  such  expo- 
sure, the  eyeball  becomes  congested  and  red  through  irritation, 
and  augments  the  patient's  unsightly  appearance.  Such  a  picture 
of  the  resultant  condition  should  be  traced  before  the  patient  by 
him  who  will  remove  the  parotid  gland. 

There  is  a  general  concurrence  of  opinion  in  regard  to  remov- 
ing the  malignant  parotidean  growth.     So  long  as  it  is  of  moder« 


526  MALAR    AND    PAKOTIDEAN    KKCIONS. 

ate  dimensions,  as  Weber  advises,  this  sliould  be  done  in  cases  in 
Avhich  the  growtlv  is  a  scirrhous  tumor  which  can  be  detached 
from  the  parts  around  it;  and  also  in  case  it  be  an  encephaloid 
tumor  which  has  not  perforated  the  aponeurotic  wall  on  the 
side  of  the  pharynx.  But  if  the  tumor  has  opened  into  the 
pharynx,  or  has  penetrated  the  internal  jugular  vein,  or  involves 
the  bones  adjacent,  the  knife  should  be  withheld. 

Operation. — The  instruments  required  for  the  operation  are 
scalpel,  retractors,  hemostatic  forceps,  blunt  dissector,  silk  and 
catgut  thread,  aneurysmal  needle,  bhmt  scissors  and  materials  for 
sponging  and  for  final  dressing. 

Various  dermal  incisions  have  been  proposed  for  exposure  of 
the  diseased  parotis.  Weber  directs  to  open  the  skin,  by  an 
incision  parallel  with  the  posterior  border  of  the  lower  jaw;  and, 
should  tliis  not  offer  an  ample  field  for  the  operation,  this  is  to 
be  enlarged  by  a  horizontal  cut  corresponding  to  the  lower 
border  of  the  maxilla.  The  skin  being  dissected  up  so  as  to 
expose  the  tumor,  some,  as  Stromeyer  and  Liston,  advise  to  open 
the  aponeurotic  covering,  and  then  to  continue  the  work  by 
enucleation.  Weber  urgentl}^  opposes  this  plan,  as  well  as  that 
of  Roser,  who  removes  a  section  from  the  diseased  gland  in  order 
to  lessen  its  volume;  but,  retaining  the  fascial  covering  intact, 
Weber  prosecutes  the  dissection  of  detachment  outside  of  this 
capsule.  When  tlie  external  attachments  are  divided,  then  Weber 
endeavors  to  get  behind  the  tumor  by  uplifting  the  lower  lobe, 
and  thence  he  continues  the  detachment  upwards;  thus  the 
external  carotid  is  reached  first  in  its  proximal  portion.  Should 
the  adherence  be  so  firm  below  that  one  cannot  enter  there,  then 
Weber  would  commence  above,  or  at  the  sides,  either  in  front  or 
behind;  and  thus  the  tumor  is  to  be  loosened  and  uplifted  from 
its  deep  connections.  Tie  vessels  which  are  met,  doubly,  and 
divide  between  the  ligatures.  Finish  the  deeper  part  of  the 
extirpation  with  care,  and  do  not  spoil,  with  undue  haste,  the 
concluding  steps  of  the  work.  Such,  in  brief,  are  the  directions 
for  the  total  removal  of  the  parotis  given  by  Otto  Weber,  whose 
diligent  researches  in  surgical  pathology  and  equally  thoughtful 
work  as  an  operator,  render  him,  in  the  opinion  of  the  writer, 
one  of  the  most  trustworthy  guides  who  have  appeared  in  this 
century.  Weber  pronounces  total  extirpation  of  the  parotis  to  be 
one  of  the  most  delicate,  subtle  and  beautiful  surgical  operations, 
and  which,  with  due  care,  can  be  done  without  much  loss  of 
blood. 


CARCINOMA.  527 

Delorme,  in  an  elaborate  exposition  of  the  principles  which 
should  govern  in  the  extirpation  of  tumors  involving  the  entire 
parotis,  makes  three  stages  of  the  work:  1.  Incision  through  the 
skin,  which  may  be  done  vertically,  crescentically,  crucially  or 
by  an  elliptical  cut  in  which  a  portion  of  the  skin  is  excised. 
2.  Detachment  of  the  overlying  derm.  3.  Separation  of  the  tumor 
from  its  deeper  connections;  and  in  this  act  some  dissect  from 
below,  upwards;  others  from  above,  downwards;  and  others 
again  detach  from  the  sides.  Bdrard  advises  to  first  dissect  up 
the  anterior  border  from  the  ramus  of  the  jaw;  then  to  loosen 
the  posterior  border  from  the  sterno-cleido-mastoid  muscle.  If 
necessary,  tie  the  external  carotid,  and  do  this  as  low  down  as 
possible,  since  in  this  way  it  will  not  be  necessary  to  tie  the  ves- 
sels which  arise  beyond  the  ligature.  Avoid,  in  the  dissection,  the 
submaxillary  gland,  the  facial  artery,  and,  especially,  the  internal 
jugular  vein,  which  may  be  endangered  in  the  deeper  portion  of 
the  detachment.  Tie  doubly  the  external  jugular  vein,  and 
divide  between  the  ligatures.  The  scalpel  must  be  dropped  as 
early  as  possible,  and  the  work  continued  with  the  fingers  or  a 
blunt  dissector. 

The  writer,  in  the  treatment  of  malignant  neoplasm  involving 
the  parotis,  has  several  times  removed  the  gland.  The  w^ork 
has  been  done  through  a  vertical  cut  through  the  skin  corre- 
sponding to  the  vertical  axis  of  the  gland;  and  to  this  was  added 
a  short  horizontal  one  in  the  line  of  the  Stenonian  duct,  and  to 
control  hsemorrhage,  the  external  carotid  w^as  tied  as  the  first  act. 
In  the  enucleation,  the  capsule  of  the  gland  should  be  included. 
Veins,  which  are  opened,  should  be  ligated  if  torsion  fails  to  con- 
trol the  bleeding.  Care  should  be  taken  that  no  glandular  frag- 
ments be  left  behind,  since  salivary  oozing  from  them  would 
prevent  closure  of  the  wound.  In  a  patient  of  sarcoma  of  the 
gland,  operated  on  in  the  manner  here  briefly  outlined,  the  writer 
obtained  complete  union  of  the  wounded  structures  in  less  than 
two  weeks. 

Sometimes  the  tumor  has  developed  independently  of  the 
parotis,  and,  in  its  growth,  it  has  pushed  the  gland  bej'ond  it,  so 
that  the  two  are  separate  from  each  other;  in  such  condition, 
the  growth  may  often  be  removed  without  ligation  of  the  external 
carotid  artery,  and  without  division  of  the  branches  of  tlie  facial 
nerve. 

In  complete  extirpation  of  the  gland  the  following  arteries 
may  be  met  in  the  dissection:  the  external  carotid,  the  temporal, 


528  MALAR    AND    PAROTIDEAX    REGIONS. 

internal  maxillary,  transverse  facial,  posterior  auricular,  occipi- 
tal, and  numerous  small  branches  distributed  to  tlie  parotis.  The 
external  jugular  vein  and  its  derivative  confluents  must  be  divided. 
The  former  operators  who  removed  the  gland  without  first  tying 
the  external  carotid,  were  compelled  to  tie  its  several  branches 
just  named;  and  the  plan  was  to  tie  each  doubly  and  divide 
between  the  ligatures.  And  even  though  the  external  carotid  be 
tied,  compensating  reflux  occurs  so  speedily  tliat  the  writer  has 
found  it  necessary  to  tie  some  of  tlie  divided  branches. 

The  operative  incision  should  be  closed  by  suture  in  its  upper 
portion ;  the  lower  portion  should  be  left  open.  The  wound,  which 
is  made,  causes,  for  a  time,  difficulty  of  swallowing,  so  much  so 
that  MacClellan  was  obliged  to  nourish  his  patient  for  a  period 
through  a  tube  passed  into  the  oesophagus.  There  have  been 
cases  in  which  there  temporarily  occurred  disturbance  of  hearing. 

Cases  have  been  reported  in  which  secondary  haemorrhage 
occurred.  In  such  an  emergency  the  writer  would  use  aseptic 
sponge  as  a  compress  on  the  bleeding  part.  And  the  sponge 
would  do  more  effective  work  were  it  first  saturated  with  dilute 
alcohol,  and  sprinkled  with  tannin.  Such  haemostatic  compres- 
sion should  be  continued  for  from  eight  to  twelve  days;  in  such 
time  the  opened  vessels  would  become  securely  occluded  with 
clotted  blood. 

The  facial  palsy  ma}^  be  complete  or  incomplete;  when  it  is 
complete,  in  a  few  cases,  the  palsy  of  the  face  has  afterwards 
partly  vanished;  and  this  can  only  be  explained  by  the  supposi- 
tion that  certain  branches  of  the  nerve  have  not  been  severed. 

Parotidean  Fistula. — Parotidean  fistula  may  arise  from  lesion 
of  the  parotid  gland,  or  of  its  excretory  duct. 

The  fistula  proceeding  from  the  parotis  is  caused  by  a  wound 
or  an  abscess  which,  implicating  the  gland,  severs  one  or  more 
of  its  component  lobules.  The  wound  causing  it  is  not  unfre- 
quently  produced  by  the  surgeon  himself  in  the  course  of  opera- 
tive work  done  in  this  region.  The  site  of  such  fistula  sliould 
be  taken  into  account,  since  it  serves  to  distinguish  the  glandular 
from  the  Stenonian  fistula.  Tlie  glandular  fistula  may  be  situ- 
ated above  or  behind  the  ear,  in  any  point  of  the  parotidean 
sulcus.  Or  it  may  open  on  the  cheek  in  front;  and  then  the 
cause  is  often  an  abscess  which  has  opened  remote  from  its 
source,  or  which  may  have  been  seated  in  the  accessory  parotis. 
And  finally,  the  fistula  may  pass  some  distance  under  the  skin, 
and  open  through  the  skin  more  or  less  remote  from  the  starting 
point. 


PAROTIDEAN    FISTULA,  529 

The  opening  may  be  as  fine  as  a  hair,  or  so  large  that  a  large 
sound  can  enter  it;  and  this  is  generally  in  the  center  of  granu- 
lative  tissue;  and,  commonly,  the  skin  around  is  sound. 

The  diagnosis  of  such  fistula  is  usually  easily  made,  since, 
during  the  act  of  mastication,  the  saliva  flows  from  the  orifice  in 
greater  or  less  amount.  Such  fistula  often  closes  spontaneously,  in 
this  particular  differing  greatly  from  the  Stenonian  fistula,  which 
often  taxes  surgical  art  to  its  utmost  to  effect  a  cure. 

Treatment. — A  variety  of  methods  have  been  resorted  to  to 
obtain  closure;  these  can  be  summarized  under  four  heads:  com- 
pression, cauterization,  suture,  and  suture  with  occlusion. 

Cases  have  been  cured  by  compression,  maintained  by  lint 
bound  upon  the  opening.  Compression  of  the  entire  parotis, 
made  with  the  view  of  causing  atrophy  of  the  gland,  has  been 
practiced.  As  a  single  means  of  treatment,  compression  has 
given  unsatisfactory  results;  if  used,  it  should  be  employed  in 
conjunction  with  cauterization  or  suture. 

Cauterization  by  means  of  a  finely  pointed  pencil  of  nitrate 
of  silver,  or  a  wire  which  has  been  heated  to  red  heat,  may  be 
used.  Or  a.  caustic  solution,  either  alkaline  or  acid,  may  be 
injected  into  the  opening. 

Suture  has  been  used;  for  this  purpose  trim  the  edges  of  the 
opening,  and  close  by  means  of  catgut  or  fine  metallic  suture. 
The  author  has  successfully  employed  the  latter  plan,  combined 
with  occlusion  of  the  sutured  wound  by  means  of  collodion, 
painted  over  the  part.  The  operation  was  repeated  three  times 
before  success  was  obtained.  Besides  occlusion  with  collodion, 
the  work  may  be  aided  by  compression  on  the  parotis,  by  which 
secretion  of  saliva  will  be  diminished.  Meantime,  movements  of 
the  mouth,  tongue  and  lower  jaw  should  be  avoided,  and  nutri- 
tion should  be  maintained  by  means  of  liquid  food. 

Stenonian  fistula  may  arise  from  wounds  which  open  the 
duct;  also  from  an  abscess  involving  the  duct.  A  rare  cause 
observed  is  a  calculus,  forming  in  the  duct,  which  enlarges  until 
it  perforates  the  walls  of  the  canal. 

The  diagnosis  of  a  Stenonian  fistula  is  made  without  diffi- 
culty; in  fact,  it  too  easily  announces  and  declares  itself  by  the 
escape  of  saliva  from  the  opening  on  the  cheek.  Though  this 
salivary  trickling  may  be  constant,  yet  it  is  greatly  augmented 
during  the  act  of  chewing  food  :  and  this  fluid,  trickling  upon  his 
person,  renders  the  patient  offensive  to  himself,  and  an  object  of 
nauseating  disgust  to  those  who  are  in  his  presence.     The  victim 


530  MALAR    AND    PAROTIDEAN    KEGIOXS. 

early  and  urgently  seeks  relief,  and  is  surprised  when  told  tliat 
the  repair  of  this  insignificant  breach  in  his  face  is  one  of  the 
most  difficult  feats  in  operative  surgery;  yet  the  patient  is  undis- 
mayed by  the  troubles  to  which  the  proposed  treatment  will 
subject  liim ;  for  if  unrelieved  he  will  be  forced  to  use  some  device 
to  catch  his  drivehng  saliva.  Morand  says  that  a  })atient  of  this 
trouble,  whom  lie  saw,  was  forced  to  use  at  his  meals  a  barber's 
basin.  From  a  patient  of  Duphoenix  there  flowed,  from  such  a 
fistula,  about  four  ounces  in  twenty  minutes.  The  disuse  of  tlie 
buccal  end  of  the  canal  causes  it  to  become  very  narrow;  and  this 
impediment  must  sometimes  be  overcome  in  the  treatment. 

Inventive  genius  has  been  diligent  in  the  searcli  for  means 
to  accomplish  the  cure  of  Stenonian  fistula;  and  many  expedients 
devised  seemed  to  have  accomplished  cures. 

In  a  thesis  on  the  subject  of  parotidean  fistula,  written,  in 
1868,  by  Mirza  Abdal  Vaherb  de  Gaffary,  the  numerous  means 
of  treatment  are  reviewed;  the  following  is  a  synopsis  of  the 
methods:  cauterization;  com})ression  made  between  the  gland 
and  the  fistula,  or  over  the  fistula,  or  on  the  gland  itself;  or 
exsection  of  the  fistula  may  be  done,  and  the  wound  closed  by 
suture.  The  work  can  also  be  done  by  dilatation  of  the  end  of 
the  canal; -or  a  derivative  canal  may  be  made  by  means  of  a  hot 
wire,  a  silken  cord,  a  canula  or  a  trocar  and  a  seton.  Or  two 
canals  may  be  formed  by  means  of  a  leaden  wire,  or  a  common 
cord.  Cures  have  been  effected  by  cauterization  of  the  fistula; 
likewise  by  injecting  into  it  some  stimulating  fluid.  The  lead- 
ing and  trustworthy  methods  consist,  in  the  main,  in  restor- 
ing the  calibre  of  the  anterior  portion  of  the  canal,  in  case 
that  has  been  contracted,  or  of  forming  an  opening  from  the 
fistula  directly  through  the  check  into  the  mouth.  The  forther 
backwards  the  site  of  the  fistula  is,  the  more  difficult  is  the  cure. 
Tillaux  says  that  if  the  fistula  be  in  the  masseteric  portion,  the 
cure  is  impossible,  or  nearly  so;  on  the  contrary,  if  seated  in  the 
anterior  or  buccal  portion,  it  is  curable.  And,  as  an  opening  in 
the  posterior  portion  might  be  mistaken  for  a  fistula  from  the 
glandular  structure,  as  distinction  between  the  two,  Tillaux  finds 
that,  in  the  glandular  fistula,  some  saliva  will  still  flow  into  the 
buccal  cavity,  while  in  case  of  the  main  duct  being  openerl,  the 
whole  of  the  fluid  escapes  on  the  cheek,  and  none  into  the  mouth. 

We  will  proceed  to  individualize  in  detail  the  methods  which 
have  been  successfully  employed  by  different  surgeons  for  the 
cure  of  this  fistula. 


PAROTIDEAX    FISTULA.  531 

Louis  sought  for  the  buccal  end  of  the  duct,  and  passed  into 
this  a  fine,  fenestrated  probe  which  carried  a  thread;  the  probe 
and  thread  were  carried  through  the  anterior  portion  of  the  duct, 
and  brought  thus  through  the  fistula.  The  thread,  being 
detached  frojii  the  probe,  was  left  in  the  entire  passage,  and,  to 
maintain  it  in  place,  the  end  within  the  mouth  was  tied  to  that 
on  the  cheek.  In  a  day  or  two  a  larger  thread  was  passed, 
and  this  was  repeated  until  the  canal  and  fistula  had  been  much 
enlarged;  this  attained,  the  cord  was  cut  off  on  the  outside,  and 
then  the  buccal  portion  was  drawn  inwards,  and  the  canal 
allowed  to  close  from  the  cheek  inwards.  This  plan  would  be 
impossible  should  there  be  closure  or  much  narrowness  of  the 
buccal  j^ortion  of  the  duct.  As  aid,  injections  may  be  made 
through  the  anterior  part  of  the  canal. 

A  method  superior  to  the  one  described  is  that  invented  by 
Deguise  in  1811.  This  consisted  in  passing  a  small  trocar  through 
the  fistula  and  forcing  the  instrument  from  before  backwards; 
through  the  canula  Deguise  ^^assed  a  leaden  wire.  Then,  from 
the  same  external  orifice,  the  trocar  was  caused  to  traverse  the 
cheek  from  behind  forwards,  and  the  other  end  of  the  leaden 
ware  was  carried  through  into  the  mouth,  when  the  ends  were 
fastened  inside.  This  method  has  served  as  the  model  of  other 
plans  in  which  the  original  is  somewhat  modified.  Instead  of 
leaden  wire,  that  of  silver  or  gold  might  be  used,  and,  after  the 
wire  is  fastened  inside  of  the  mouth,  the  edges  of  the  fistula  may 
be  pared,  and  the  external  wound  closed  by  suture.  The  looped 
wire  should  be  tightened,  from  time  to  time,  so  that  it  may  grad- 
ually cut  through  the  included  portion  of  the  cheek.  Silken 
cord  might  be  used  instead  of  wire,  or  a  small  canula  might  be 
passed  in  from  the  fistula  and  retained  in  the  cheek,  so  as  to  per- 
mit the  saliva  to  enter  the  mouth  after  the  outer  opening  is 
sutured. 

The  treatment  has  been  directed  to  the  outer  opening  alone ; 
the  plans  here  used  have  been  suture,  cauterization  and  compres- 
sion. 

The  edges  of  the  fistula  may  be  trimmed  and  then  united  by 
suture,  and  this  will  be  aided  if  covered  by  a  thick  coating  of 
collodion.  A  cure  might  thus  be  effected,  provided  the  anterior 
portion  of  the  canal  is  yet  patent;  and  should  this  be  contracted, 
it  must  be  dilated  by  the  use  of  appropriate  sounds. 

Closure  has  been  attempted,  yet  rarely  successfully,  by  cauter- 
ization of  the  fistula  by  means  of  a  pencil  of  nitrate  of  silver,  or 
the  thermal  cautery. 


532  MALAR    AND    I'AROTIDEAN    RKGIONS. 

Compression  has  been  tried,  and  this  may  be  applied  on  the 
outer  opening,  so  as  to  [)reveiit  the  escape  of  saliva;  or  the  pres- 
sure may  be  made  on  the  gland,  so  as  to  check  the  secretion  of 
saliva. 

Claude  Bernard  has  found  in  vivisective  experiment  that,  if 
the  salivary  duct  be  tied  and  the  secretion  thus  retained  behind 
the  ligature,  atrophy  of  the  gland  will  ensue.  Some  have  coun- 
seled to  utilize  this  fact  in  the  cure  of  salivary  fistula.  The  few 
reports  of  trials  of  this  plan  do  not  encourage  its  repetition. 

Viborg,  after  severing  the  duct  in  animals,  reunited  the  ends 
by  suture;  and  as  union  occurred,  he  proposed  direct  suture  as  a 
plan  of  curing  Stenonian  fistula. 

The  ingenious  Langenbeck  proposed  to  dissect  up  the  poste- 
rior end,  and  turn  the  same  into  the  mouth  through  an  opening 
made  inwards  through  the  tissues.  The  objection  to  this  plan  is 
that  the  end  which  has  thus  been  shifted  tends  to  retract,  and 
the  buccal  orifice  becomes  narrowed  or  closed. 

Desault  proposed  to  dry  up  the  fountain  by  compression 
maintained  on  the  gland,  so  as  to  cause  its  atrophy.  It  is  proba- 
ble that  the  offspring  of  modern  civilization  would  rebel  against 
such  a  painful  plan  of  treatment. 

Bonafont  reports  that  he  cured  a  salivary  fistula  in  1841  by 
dissecting  up  the  posterior  part  of  the  duct,  and,  having  fastened 
the  end  in  a  small  canula,  the  latter  was  passed  through  the 
cheek  into  the  mouth,  and  retained  there  during  the  healing  of 
the  outer  fistula,  which  was  closed  by  suture.  In  1851,  Balassa 
reported  a  cure  by  a  modification  of  the  plan  of  Deguise,  above 
mentioned.  In  18(31,  Consolini  cured  a  Stenonian  fistula  by  pass- 
ing a  catgut  thread  through  the  anterior  portion  into  the  pos- 
terior one,  and  retaining  the  thread  in  place  until  the  outer 
fistula  healed.  In  1882,  Stokes,  of  Dublin,  cured  a  case  in  a 
similar  way,  yet,  instead  of  catgut  thread,  he  used  a  wire. 

In  conclusion,  it  is  clear  that  there  is  no  dearth  of  methods 
from  which  the  surgeon  may  make  selection  for  the  cure  of  parot- 
idean  or  Stenonian  fistula;  and  it  is  probable  that  by  a  dili- 
gent prosecution  of  any  one  of  them,  a  cure  of  the  patient  will  be 
attained. 


CHAPTER  XV. 


MAXILLA    SUPERIOR. 


Fracture. — Reference  has  already  been  made  to  fracture  of 
the  upper  jaw  which  existed  coincidently  with  a  lacerated  wound 
of  the  cheek;  mention  was  also  made  of  subcutaneous  fracture  of 
the  anterior  wall,  in  which  the  latter  is  forced  into  the  antrum; 
there  yet  remains  to  be  considered  certain  fractures  of  the  maxilla 
superior  which  involve  the  processes  or  the  body  of  this  bone. 

The  alveolar  process  may  be  broken,  on  a  small  scale,  in  the 
act  of  extracting  teeth ;  yet  the  improved  methods  of  dentistry,  in 
which  the  forceps  has  replaced  the  lever  and  key,  have  rendered 
such  fracture  a  more  rare  occurrence.  The  roots  of  the  molar 
teeth  are  sometimes  disposed  in  such  divergent  position,  or  these 
roots  so  embrace  a  portion  of  the  process,  that  the  teeth  cannot 
be  extracted  without  causing  some  fracture  of  the  process.  And 
this  injury  may  consist  merely  of  a  small  piece  of  bone  broken 
from  the  inner  or  outer  wall  of  the  alveolus;  or  the  rent  may 
include  a  considerable  portion  of  the  alveolar  process;  or,  finally, 
it  may  involve  the  body  of  the  jaw. 

When  a  minute  fragment  of  the  alveolus  is  broken  off,  the 
conditions  are  such  that  it  usually  dies,  and,  if  not  removed  at 
the  time,  it  will  sooner  or  later  become  separated  by  suppuration. 
The  condition  is  somewhat  more  grave  and  requires  more  atten- 
tion when  a  portion  of  the  process  containing  one  or  more  teeth 
is  broken  off.  An  injury  of  this  kind  is  to  be  treated  by  restoring 
the  fragment  to  proper  site,  retaining  it  there,  and  maintaining 
it  in  rest.  The  replacement  is  easily  done;  retention  in  site  is 
more  difficult;  this  may  sometimes  be  done  by  ligating  the  teeth 
of  the  fragment  to  those  outside  of  it  by  means  of  wire  or  silken 
cord.  Wire  is  more  easily  used,  yet  thread  is  less  apt  to  injure 
the  teeth.  If  retention  in  place  is  thus  impracticable,  as  is  the 
case  in  which  a  large  portion  of  the  process  is  broken,  and  by  its 
weight  separates  from  the  body,  then  a  mold  of  gutta  percha 
should  be  applied  to  the  part,  and  the  lower  jaw  brought  against 

(533) 


53-4  MAXILLA    SUPERIOR. 

the  upper  one  and  held  there  by  a  bandage  placed  around  the 
head.  Meantime  the  patient  must  be  fed  on  liquid  food.  This 
food  may  be  introduced  through  a  tube  passed  into  the  buccal  cav- 
ity,  around  and  behind  the  molar  teeth;  or,  if  there  be  a  breach  in 
the  teeth  of  the  lower  jaw,  the  food  may  be  introduced  there. 
During  this  closure  of  the  teeth,  the  cavity  of  the  mouth  must  be 
rinsed  out  two  or  three  times  daily  by  injecting  into  it  a  weak 
solution  of  borax:  thus  parasitical  multiplication  is  averted,  and 
jnore  rapid  healing  insured.  Under  this  management  speedy 
eunion  of  the  fracture  ensues  in  from  three  to  four  weeks. 

In  case  a  portion  of  the  body  of  the  jaw  is  detached  with  the 
alveolar  process,  then  a  similar  plan  of  treatment  is  to  be  pur- 
sued; special  care,  however,  is  to  be  taken  that  the  displaced  frag- 
ment be  accurately  replaced  and  retained  in  normal  site.  After 
the  healing  of  the  fractured  alveolar  process, should  there  remain 
some  inequality  in  the  position  of  the  teeth,  this  will  commonly 
disappear  through  the  work  of  mastication,  in  which  pressure  on 
the  dependent  part  tends  to  force  it  into  normal  place. 

The  body  of  the  maxilla  superior  is  so  situated  that  it  is  pro- 
tected from  the  usual  causes  of  violence  which  produce  fracture 
elsewhere  in  the  body;  and,  excepting  projectiles  which  also 
wound  the  soft  parts,  the  fracture  of  the  upper  jaw  through 
indirect  or  direct  impact  of  force,  is  rare. 

Fracture  resulting  from  indirect  violence  has  been  studied  by 
Lelieribel,  who  finds  that  this  bone  is  protected  by  three  sets  of 
osseous  columns,  viz.,  the  fronto-nasal  in  the  median  line,  the 
malar  and  the  zygomatic  at  the  sides,  and  lastly  the  pterygoid 
processes,  which  support  the  bone  behind.  Violence  is  oftenest 
transmitted  to  the  upper  jaw  through  the  maxilla  inferior;  for 
example:  a  blow  on  the  chin  may  break  the  lower  jaw;  or,  this 
part  escaping,  the  violence  may  travel  to  and  break  the  upper 
jaw.  In  a  second  way,  when  the  lower  jaw  is  fixed,  violent  force 
acting  on  the  summit  of  the  head  has  been  known  to  fracture 
the  maxilla  superior.  And  in  a  third  way,  the  bone  may  be 
broken  by  the  j)atient  falling  some  distance  and  striking  on  the 
chin.  And,  lastly,  fracture  has  arisen  from  violence  acting  on 
the  malar  bone,  and  driving  this  bone  downwards  and  inwards. 

Guerin,  in  experiments  on  the  cadaver,  found  that  a  blow  on 
the  face  below  the  nose  causes  a  horizontal  fracture  traversing 
the  maxilla  below  the  malar  bones;  and  the  pterygoid  ])rocesses 
are  likewise  broken.  In  such  case,  if  the  finger  be  passed  behind 
the  molar  teeth  and  pressure  be  made  on  the  pterygoid  plate. 


FRACTURE.  535 

tlie  latter  will  be  felt  to  move;  or,  if  it  is  not  moved,  such,  pres- 
sure awakening  pain  is  indicative  of  fracture;  and  the  move- 
ment mentioned  and  the  pain  awakened  are  pronounced  by 
Guerin  to  be  trustworthy  diagnostic  signs  of  fracture  of  the  upper 
jaw. 

In  the  cases  of  fracture  resulting  from  indirect  violence,  the 
diagnosis,  as  just  seen,  may  be  difficult  to  determine;  on  the  con- 
trary, cases  occur  in  which  the  condition  is  clearly  evident 
through  the  displacement  of  the  bone.  The  two  bones  may  be 
separated  from  each  other,  and  one  may  be  movable,  and  some- 
what depressed  below  the  other;  or  both  of  the  maxillse,  with- 
out injury  of  their  median  synosteal  suture,  may  be  detached 
from  their  upper,  lateral  and  posterior  connections,  and  may 
hang  loosely  over  the  oral  cavity.  The  writer  has  seen  and 
treated  a  case  of  the  latter  kind,  which  resulted  from  a  cable-car 
accident,  and  the  violence  was  probably  direct,  as  the  cheeks 
were  greatly  contused.  There  was  no  open  wound.  The  max- 
illse,  as  a  common  mass,  were  movable,  and  rested  on  the  lower 
jaw.  There  was  serious  encephalic  injury,  in  which  cerebral 
concussion  was  prominent. 

In  fracture  caused  by  direct  or  indirect  violence,  vascular 
rupture  must  occur;  and  should  the  bones  be  displaced,  this 
rupture  will  be  so  extensive  as  to  cause  swelling  and  visible 
ecchymosis.  Such  ecchymosis  may  be  found  in  the  roof  of  the 
mouth,  or  in  the  tissues  investing  the  base  of  the  alveolar  process. 
Such  swelling  and  blood  marks  aid  in  the  determination  of  the 
fracture,  when  there  is  no  mobility. 

Fracture  of  the  upper  jaw  may  have  as  ill  consequences 
obstruction  or  closure  of  the  lachrymal  canal,  pressure  on  some 
of  the  branches  of  the  superior  maxillary  portion  of  the  trifacial 
nerve,  and  irregularity  of  the  dental  row  through  displacement  of 
the  alveolar  process.  To  avoid  these  results,  which  may  amount 
to  grave  annoyances,  the  surgeon  in  charge  should  accurately 
restore  the  fractured  part,  or  parts,  to  their  normal  site,  and 
afterwards  retain  them  at  rest  until  union  has  taken  place. 
Restoration  to  place  may  be  done  with  the  fingers  and  a  blunt 
instrument,  such  as  a  sound  passed  into  the  nostrils.  That  the 
lachrymal  canal  is  open  will  be  shown  by  the  tears  passing 
through  their  natural  channel ;  but  if  the  canal  be  obstructed, 
the  tears  will  flow  over  the  lower  lid.  Another  rare  accident  is 
the  emphysematous  infiltration  of  the  tissues,  due  to  air  being 
forced  into  them  during  strong  expiratory  effort  through  the 
nasal  passages. 


536  MAXILLA    SUPERIOR. 

Fracture  of  the  maxilla  superior  is  remarkable  for  the  short 
time  required  for  healing,  provided  the  i)arts  be  placed  in  proper 
position,  and  thus  immobilized.  After  coaptation,  if  alveolar 
fracture  demand  it,  let  the  teeth  be  encased  in  gutta  percha,  and 
then,  by  a  bandage,  fix  the  lower  jaw  against  tlie  upper  one,  so 
as  to  retain  the  latter  in  position.  Meantime,  during  the  four 
weeks,  which  time  is  demanded  for  healing,  let  the  patient  be  fed 
in  the  manner  already  described.  The  appliance  of  retention 
may  be  a  gypsum  cast;  or  straps  with  buckles  may  l)e  placed 
vertically,  obliquely  and  horizontally,  so  as  to  maintain  rest  of 
the  broken  bone. 

Fracture  from  gunshot  wound  has  often  been  observed  by  the 
military  surgeon;  and  in  this  era  of  social  discord,  in  which  the 
worst  as  well  as  the  best  elements  are  evenly  paired  in  the  turmoil 
of  civilization,  the  civil  surgeon  is  not  an  infrequent  observer  of 
gunshot  injuries;  such  injury,  self-inflicted,  may  be  the  gunshot 
wound  in  the  mouth,  which  failing  to  kill,  as  was  intended,  the. 
ball  has  shattered  the  upper  jaw.  Such  projectile  wound  should 
be  treated  in  the  same  manner  as  gunsliot  wounds  in  other  |)arts 
of  the  body;  especial  care,  however,  should  be  taken  to  save 
fragments  of  the  palatal  orocess  wliich  are  still  adherent  to  the 
soft  parts. 

Resection  of  the  Upper  Jaw. — Resection  of  the  maxilla  superior 
may  be  partial  or  total  in  its  extent;  partial  resection  may  con- 
cern either  the  processes  or  a  portion  of  the  body;  but  in  total 
resection  the  entire  bone  or  both  maxillae  may  be  extirpated. 
Tn  total  resection  the  inferior  turbinated  bone  is  necessarily 
removed,  inasmuch  as  it  articulates  only  with  the  upper  jaw. 
On  the  other  hand,  though  resection  is  said  to  be  total,  yet,  in 
most  cases  in  which  it  is  done,  fragments  of  the  articulating 
processes  are  left  behind. 

Resection  is  also  done  temporarily,  in  wliich  a  part  of  the 
bone  is  loosened  and  uplifted  in  connection  with  the  soft  parts, 
for  the  purpose  of  reaching  growths  situated  in  the  antrum,  the 
nasal  cavities  or  the  naso-pharyngeal  region;  and  after  this  pur- 
pose is  accomplished,  the  bone  is  replaced. 

Resection  is  often  done  for  the  jiurpose  of  removing  a 
malignant  neoplasm  which  implicates  a  part  or  the  whole  of 
the  bone;  for  the  maxilla  superior,  like  its  close  neighbor,  the 
parotis,  is  the  germinal  site  of  the  various  malignant  growths; 
and  if  these  do  not  arise  in  it,  they  may  reach  it  by  extension. 
Exceptionally,  resection  is  required  for  the  removal  of  benign 


RESECTION    OF    THE    UPPER    JAW.  537 

tumors.  These  -anfortunate  prerogatives  belong  to  both  the 
uj^per  and  the  lower  jaw. 

O.  Weber  has  collected  three  hundred  and  seven  cases  of 
tumors  of  the  upper  jaw,  which  he  classifies  under  the  following 
heads:  osteoma,  thirty-two;  vascular  tumor,  one;  fibroma  and 
vascular  fibroma,  seventeen;  sarcoma,  eighty-four;  enchondroma, 
eight;  cysts,  twenty;  mucous  polypi,  seven;  carcinoma,  one  hun- 
dred and  thirty-three,  and  melanoma,  five,  Weber  thinks  that 
some  of  the  cases  of  carcinoma  should  have  been  placed  under 
the  head  of  sarcoma,  since  he  believes  that  nearly  half  of  maxil- 
lary tumors  are  sarcomatous  in  nature. 

In  case  the  disease  requiring  resection  is  limited  to  the  palatal 
or  alveolar  j^rocess,  or  is  situated  in  a  portion  of  the  maxilla 
superior,  then  partial  resection  is  the  proper  operation  to  be  done. 
In  such  partial  resection,  the  guiding  rule  should  be  to  excise 
enough  of  the  bone  so  as  to  completely  remove  the  disease;  to 
spare  the  parent  bone  and  permit  the  early  reappearance  of  the 
disease  would  be  ill  economy.  The  excising  knife  or  chisel  should, 
in  its  girdling  cut,  reach  into  the  sound  structure,  and,  in  fact, 
comj)rise  a  few  lines  of  the  latter  inside  of  the  line  of  excision; 
only  thus  operating  can  a  satisfactory  result  be  obtained. 

The  resection  of  a  portion  or  of  the  entire  alveolar  j^rocess  is 
done  as  follows :  An  incision  is  to  be  made  between  the  cheek  and 
the  jaw,  in  the  bottom  of  the  fossa  between  the  two  parts,  and  the 
cheek  is  to  be  dissected  from  the  jaw  to  a  sufficient  distance  to 
expose  the  outside  of  the  bone  which  is  to  be  divided.  This 
separation  is  best  done,  after  the  first  cut  is  made  with  the  scalpel, 
by  means  of  a  chisel,  with  which  the  periosteum  is  uplifted.  A 
similar  cut,  and  concentric  with  the  first  incision,  is  to  be  made  on 
the  palatal  side  of  the  alveolar  process.  The  vertical  cuts  are 
now  to  be  made  through  the  bone,  including  the  afiiected  part. 
To  make  these  cuts,  it  is  often  necessary  to  extract  one  or  more 
teeth  which  stand  in  the  line  of  the  incision.  Next  a  horizontal 
cut  uniting  the  vertical  ones  is  to  be  made.  This  third  cut  com- 
pletes the  separation  of  the  diseased  part.  The  division  of  the 
bone  may  be  done  with  a  resection  saw,  chisel  and  mallet,  or 
with  large,  strong-bladed  forceps.  If  forceps  be  used,  there 
should  be  two  pairs,  one  with  straight  blades  for  the  vertical 
cutting,  and  another  curved  pair  to  divide  horizontally.  The 
chisel  and  mallet  are  favorite  instruments  of  the  French  in 
maxillary  resection;  the  division,  thus  done,  leaves  a  more  irregu- 
lar surface  than  if  the  removal  be  done  with  the  resection  saw. 
35 


538  MAXILLA    SUPERIOR. 

This  instrument  witli  its  narrow  blade  can  be  used  in  any  direc- 
tion, and  at  any  angle.  The  author  has  operated  according  to 
each  of  the  methods  mentioiied,  and  gives  his  preference  to  the 
saw,  especially,  if  along  with  it,  there  be  used  a  small  trephine, 
with  which  openings  may  be  made  at  the  point  of  union  of  tlie 
vertical  and  horizontal  lines  of  section;  for  the  narrow-bladed 
saw  can  be  passed  in  such  opening,  and  thence  the  sawing  can  be 
done  in  both  directions. 

This  alveolar  resection  can  be  done  through  the  moutii,  and 
hence  without  external  scar.  Should  the  opening  of  tlie  moutli 
be  too  narrow,  then  more  room  could  be  gotten  by  extending  the 
angle  of  the  mouth  by  means  of  a  horizontal  cut;  and  such  a 
cut  would  leave  an  inconspicuous  scar.  To  assist  in  doing  the 
work  through  the  mouth,  the  oral  opening  can  be  held  open  and 
dilated  and  shifted  from  its  site  by  means  of  large  retractors. 

A  growth  seated  on  the  anterior  surface  of  tlie  superior 
maxilla  and  limited  to  tliis  face,  may  also  be  removed  through 
the  mouth.  To  do  this,  incise  through  the  labio-maxillary  fossa, 
and  with  a  blunt  dissector  separate  the  structures  of  the  cheek 
from  the  maxilla;  and  this  detachmen*  ^.an  be  carried  to  the  infra- 
orbital margin.  To  aid  in  this  dissection,  the  mouth  may  be 
shifted  upwards.  In  this  wise  the  writer  excised  an  osteomatous 
growth  already  referred  to,  involving  the  front  face  of  the 
maxilla. 

The  total  excision,  or  resection,  as  it  is  oftener  named,  of  the 
upper  jaw  has  been  the  matter  of  emulous  effort  among  operative 
surgeons.  Among  those  who  have  earned  distinction  in  this 
field  are  the  names  of  Gensoul,  Lizars,  ISIichaux,  Dieffenbach, 
Heyfelder,  Langenljeck  and  0.  Weber.  A  diagrammatic  repre- 
sentation of  the  lines  of  incision  would  present  a  face  well 
traversed  with  sections.  If  these  lines  be  studied  as  to  their 
position  and  direction,  one  finds  a  frequent  one  to  be  a  vertical 
median  line  from  the  lower  part  of  the  forehead  (glabella),  along 
the  dorsum  of  the  nose,  through  the  upper  lip  into  the  mouth; 
or,  instead  of  in  the  median  line  of  the  nose,  the  incision  may  be 
made  vertically  alongside  of  the  nose  to  the  mouth;  in  a  third 
method,  the  incision  is  made  from  the  angle  of  the  mouth,  or 
from  some  point  of  the  border  of  the  upper  lip,  upwards  and 
obliquely  outwards.  This  oblique  cut  has  been  given  various 
positions  on  the  cheek;  and  it  may  be  straight  or  curved. 
And,  lastly,  a  horizontal  cut  may  be  made  from  the  nose  outwards, 
close  to  the  lower  border  of  the  orbit. 


RESECTION    OF    THE    UPPER    JAW.  539 

In  the  pioneer  work  done  by  Gensoul  and  Lizars,  the  maxilla 
was  exposed  by  a  quadrangular  flap,  which  was  made  by  two 
vertical  cuts,  viz.,  one  which  was  made  alongside  of  the  nose, 
and  another  extended  directly  upwards  from  the  angle  of  the 
mouth.  The  lateral  or  outer  cut,  in  this  method,  divided  many 
branches  of  the  facial  nerve  as  well  as  the  duct  of  Stenson;  and 
thus  the  unfortunate  patient  remained  with  a  palsied  cheek  and  a 
salivary  fistula;  conditions  which,  if  not  as  fa:tal  to  life  as  the 
growth  which  is  to  be  removed,  certainly  render  existence 
scarcely  tolerable.  And  to  avoid  these  ill  results,  the  outer 
vertical  cut  was  abandoned. 

The  following  review  of  resection  of  the  superior  maxilla, 
drawn  from  the  published  work  of  eminent  authorities,  will  j^re- 
sent  in  somewhat  historic  order  the  various  methods  which  have 
been  pursued. 

The  quadrangular  flap  of  Gensoul  being  abandoned,  for  the 
reasons  before  given,  DiefFenbach,  in  1847,  published  thirty-two 
operations  in  whicH  the  removal  was  done  through  a  vertical  cut 
which  passed  from  the  inner  angle  of  the  eye  to  the  mouth,  and 
which  was  aided  by  a  horizontal  cut  beneath  the  eye;  thus  done, 
the  facial  nerve  was  spared. 

Michaux,  in  1852,  removed  the  superior  maxilla  to  form  a 
way  by  which  he  could  enter  the  posterior  nares  and  remove 
naso-pharyngeal  growths;  and,  in  his  method,  he  discards  the 
removal  of  the  malar  bone  as  done  by  Gensoul,  and  exposes  the 
maxilla  through  a  median  incision  which  reaches  from  the  lower 
part  of  the  forehead  along  the  dorsum  of  the  nose  downwards: 
into  the  mouth;  and  this  may  be  aided  by  a  horizontal  cut 
underneath  the  eye;  and,  if  need  be,  a  third  cut  may  extend  from 
the  outer  angle  of  the  eye  to  a  point  beneath  the  zygoma.  As 
far  as  the  disease  will  permit,  save  the  zygomatic,  nasal  and 
palatal  processes  of  the  maxilla.  To  do  bilateral  maxillary 
resection,  Michaux  counsels  to  use  the  long  cut  in  the  median 
line  of  the  face.     He  uses  the  chisel  and  mallet  as  more  manage- 

o 

able  instruments  than  the  Listen  forceps,  or  the  chain-saw. 
Michaux  performed  fifteen  resections,  of  which  seven  died  from 
purulent  infection. 

Oscar  Heyfelder,  son  of  J.  F.  Heyfelder,  in  1857  wrote  on 
maxillary  resection :  a  work  inspired  by  filial  devotion,  in  which 
the  methods  pursued  by  the  father  were  compared  with  those  of 
other  surgeons.  The  father,  in  1852,  was  the  first  to  perform 
resection  of  both  maxillse.     This  was  done  by  two  lateral  cuts 


540  MAXILLA  supp:rior. 

extending  on  each  side  from  the  malar  bone  to  tlie  angle  of 
the  mouth.  The  large  Hap  tlius  formed,  including  the  nose,  was 
dissected  up  and  turned  upwards.  The  malar  bone,  separated 
■''rom  the  upper  jaw  by  the  chain-saw,  was  preserved.  And  the 
soft  parts  lining  the  palatal  process  were  loosened  and  separated 
as  the  last  act  of  the  detachment.  As  cuts,  which  may  be  used,  the 
Heyfelders  employed  a  central  median  one  and  an  oblique  lat- 
eral one;  the  latter,  commencing  at  the  angle  of  the  mouth,  may 
run  upwards  and  outwards,  and  terminate  at  the  anterior,  middle 
or  posterior  part  of  the  malar  bone.  As  a  rule,  the  maxilla,  with 
the  tumor,  can  be  removed  through  the  oblique  lateral  cut;  and 
the  advantages  resulting  from  it  are  that  tliere  remains  but  one 
scar;  its  disadvantages  are  that  it  must  sever  branches  of  the 
facial  nerve,  and  might  divide  the  duct  of  Stenson.  The  maxilla 
superior  can  also  be  exposed  by  an  anterior  lateral  flap  that  lies 
along  the  side  of  the  nose;  and  to  this,  two  horizontal  incisions  ma}' 
be  added,  one  underneath  the  63^0,  and  one  continued  outwards 
from  the  angle  of  the  mouth;  and  thus  a  lar^e  quadrangular  flap 
is  so  formed  that  the  salivary  duct  and  the  facial  nerve  are  spared. 
This  quadrangular  flap  is  the  one  preferred  by  Heyfelder  for 
resection  of  the  upper  jaw. 

In  case  partial  resection  is  to  be  done,  then  Heyfelder  advises 
the  incision  of  Kilchler,  viz.,  a  cut  one  and  one-half  inches  long, 
passing  from  the  mouth  upwards  alongside  of  the  nose. 

Should  it  be  needed  to  remove  the  lower  jaw  along  with  the 
upper  one,  Heyfelder  advises  to  do  this  through  a  cut  made  from 
the  forehead  to  the  point  of  the  chin;  and  another  cut  wliicli 
jDasses  along  the  lower  margin  of  the  maxilla  inferior,  and 
upwards  along  the  ramus. 

In  all  these  operations,  Heyfelder  advises  to  uplift  and  retain 
the  periosteum,  when  this  is  possible.  When  necessary,  separate 
the  upper  jaw  through  the  median  suture  by  which  the  two  are 
connected.  Large  forceps  may  be  used  to  separate  the  maxilla 
from  the  bones  with  which  it  is  articulated  ;  in  many  cases,  how- 
ever, Heyfelder  prefers  the  chain-saw,  which  he  carries  around 
the  part  to  be  divided  by  the  aid  of  a  curved  needle,  which  formed 
three-fourths  of  a  circle,  of  which  the  diameter  was  from  four- 
teen to  sixteen  lines.  Such  a  needle  attached  to  the  chain  can 
be  carried  through  the  lachrymal  canal  into  the  nose.  Bellocq's 
canula  may  be  used  for  passing  the  chain-saw.  The  posterior 
articulation  of  the  jaw  with  the  sphenoid  bone  must  be  carefully 
separated ;  and  this  may  be  done  with  a  chisel.     After  the  detach- 


EESECTIOX    OF    THE    UPPER    JAW.  541 

ment  of  the  maxilla  from  the  neighboring  bones,  as  it  is  being 
removed,  divide  the  iufra-orbital  nerve  with  scissors.  Heyfelder 
did  not  dress  the  wound  for  several  hours.  The  labial  cuts  were 
sutured,  and  no  lint  placed  in  the  wounded  cavity.  Bleeding 
was  slight  and  did  not  occur  secondarily.  For  two  days,  cold 
dressings  were  used;  then  warm  ones  were  applied.  The  patient 
was  fed  with  food  injected  into  the  oesophagus.  Recovery  was 
most  rapid,  viz.,  in  from  two  to  three  weeks. 

Heyfelder  published,  in  1858,  that,  in  a  lisu  of  three  hundred 
and  fifteen  maxillary  resections,  there  had  been  secondary  bleed- . 
ing  in  only  five  cases ;  and  this  absence  of  haemorrhage  he  refers 
to  the  fact  that  he  did  not  plug  up  the  wound. 

Springer,  in  1860,  in  a  publication,  offered  some  new  sugges- 
tions, partly  his  own,  and  partly  those  of  others,  on  maxillary 
resection;  he  advises  to  spare  the  palate  and  mucous  membrane 
as  much  as  possible;  also,  to  perform  partial,  instead  of  total, 
resection  in  all  cases  where  it  is  possible.  The  outer  parts  must 
be  sutured  to  the  mucous  membrane  where  the  latter  remains. 

An  example  in  whicli  the  incision  was  as  limited  as  possible 
was  that  of  Butcher,  in  which  the  greater  portion  of  the  maxilla 
superior  was  resected  through  a  cut  made  from  the  mouth  into 
the  nostril,  and  then,  with  one  blade  of  a  pair  of  strong  forceps 
in  the  mouth  and  the  other  in  the  nostril,  the  bone  was  divided 
in  the  median  line;  and  then,  having  extracted  a  tooth  behind, 
a  similar  lateral  division  of  the  bone  was  made  at  the  side;  thus 
a  portion  of  the  jaw  was  removed. 

In  1862,  Liicke  reported  that  B.  Langenbeck  had  performed 
two  bilateral  resections  of  the  upper  jaw  witli  no  death;  but  of 
eighteen  unilateral  resections  two  died,  and  of  twenty-eight  par- 
tial resections  one  died.  Death  after  removal  of  the  jaw  arose 
from  pus  passing  down  to  the  lungs  and  causing  pneumonia;  and 
to  avert  the  swallowing  of  pus,  Liicke  advises  to  do  the  work,  as 
far  as  practicable,  sub-periosteally.  After  total  maxillary  resection, 
there  occurred  suppuration  of  the  eye  in  a  few  cases,  and  this 
was  referred  to  destruction  of  the  trifacial  nerve;  and  as  a  means 
to  avoid  such  accident,  Liicke  directs  to  close  the  eye  with  adhe- 
sive plaster. 

To  remove  the  upper  jaw  Langenbeck  makes  two  incisions; 
one  of  these  commences  on  the  glabella  between  the  eyebrows,  or 
beneath  the  internal  palpebral  ligament ;  thence  the  cutis  carried 
down  to  the  wing  of  the  nose,  and,  from  the  lower  end  of  this 
incision,  another  is  carried  upwards  and  outwards  to  the  zygoma. 


542  ^r AXILLA    SUPKRIOK. 

By  means  of  these  incisions  the  soft  i)arts  are  uplifted,  and  the 
work  can  be  done,  to  some  extent,  without  entering  the  buccal 
cavity.  Langenbeck  uses  a  fine  saw  to  separate  the  jaw  from  its 
surrounding  osseous  attachments,  the  saw  being  passed  into 
small  crevices  or  openings. 

Weber  operated  similarly  to  Langenbeck,  viz.,  b}'  means  of  a 
vertical  cut  runnnig  from  beneath  the  inner  angle  of  the  eye  to 
the  mouth;  and  this  was  aided  by  a  horizontal  cut  under  the  eye, 
in  case  it  were  necessary  to  remove  a  part  or  the  whole  of  the 
malar  bone.  If  the  periosteum  be  sound,  it  should  be  uplifted 
with  the  soft  parts  and  retained.  Weber  prefers  to  divide  the 
osseous  attachments  with  the  resection  saw,  which  is  used  as  fol- 
lows: The  saw  is  carried  into  the  orljit  under  the  uplifted  peri- 
osteum, and  the  bone  divided  thence  to  the  opening  of  the  nose; 
or,  the  saw  entering  first,  the  nasal  o])ening  may  be  cut  towards  the 
inner  part  of  the  orbit.  The  parts  being  uplifted  outwards  until 
the  saw  can  be  i:»assed  into  the  inferior  orbital  fissure,  the 
section,  started  in  the  inner  or  outer  portion  of  this  crevice,  may 
include  and  remove  a  fractional  portion  or  the  entirety  of  the 
malar  bone.  The  concluding  act  is  to  saw  through  the  palatal 
bone,  in  which,  if  possible,  the  soft  part  with  the  periosteum 
should  be  preserved.  In  this  sawing,  the  soft  })arts  should  be 
retracted  from  the  cutting  instrument  with  the  fingers  or 
retractors. 

Lehmann,  in  1864,  proposed  in  maxillary  resection,  of  the 
upper  or  lower  jaw,  to  save  the  alveolar  process  and  the  teeth 
contained  in  them.  His  plan  is  to  detach  and  reflect  from  the 
process  the  investing  soft  parts;  next,  saw  through  the  base  of 
the  alveolar  process,  so  as  to  j^reserve  as  great  a  portion  as  the 
conditions  will  permit.  If  the  entire  alveolar  quadrant  cannot 
be  saved,  preserve  a  section  of  it.  The  teeth,  thus  saved,  can 
afterwards  be  used  for  mastication.  New  bone  seemed  to  grow 
on  the  portion  of  process  thus  saved.  The  teeth  retained  their 
color  and  lustre.  Kolliker  teaches  that  the  teeth  depend  for  their 
nutrition  on  the  pulpa  dentis  and  the  contiguous  tissue  of  the 
alveolus,  and  Lehmann's  observations  confirmed  this.  Lehmann 
claims  for  his  method  that,  by  it,  the  teeth,  which  are  commonly 
lost  in  the  work  of  resection,  may  be  saved. 

As  conclusion  of  the  chapter  on  resection  of  the  maxilla  supe- 
rior, it  is  appropriate  to  describe  an  operation  akin  to  it,  viz., 
temporary  resection  of  the  upper  jaw.  In  1861  B.  Langenbeck 
wrote  on  osteoplasty,  in  which  a  bone  is  moved  or  shifted  from  its 


EESECTIOX    OF    THE    UPPER    JAW.  543 

* 

site,  and  afterwards  replaced  again;  such  an  operation  Laugen- 
beck  performed  on  the  maxilla  superior,  to  make  a  route  by 
which  naso-pharyngeal  growths  could  be  reached  and  removed. 
Michaux  advocated  the  same  procedure,  clainaing  that  these 
growths  could  only  be  successfully  extirpated  through  the  removal 
of  their  periosteal  attachments.  Langenbeck  was  led  to  tem- 
porary resection  of  the  maxilla  superior,  by  the  good  results  which 
followed  temporary  resection  of  the  nasal  bones  to  aid  in  the 
removal  of  polypus.  And  to  reach  growths  in  the  spheno-palatine 
fossa,  the  sphenoidal  sinus  and  the  Eustachian  tube,  Langenbeck 
found  that  the  work  may  be  done  by  temporarily  shifting  the 
site  of  the  body  of  the  upper  jaw.  From  a  study  of  the  facial 
skeleton,  Langenbeck  conceived  the  design  of  detaching  the 
upper  jaw  from  its  place  by  sawing  it  through  in  certain  direc- 
tions, so  that  the  body  remained  only  connected  by  its  nasal 
process  to  the  nasal  and  frontal  bones.  The  jaw  was  sawn 
through  horizontally  above  the  alveolar  process,  also  verticallv 
at  the  side.  The  vertical  cut  is  placed  so  far  laterally  that  it 
includes  the  malar  bone,  and,  when  the  sawing  is  done,  the  part 
included  is  loosened  and  lifted  upwards  and  inwards.  After  the 
tumor  has  been  removed,  the  shifted  bone  is  to  be  replaced,  and 
if  it  does  not  remain  in  normal  site,  it  should  be  retained  there 
by  metallic  sutures. 

Demarquay  announced  in  1862  that,  since  1851,  he  had  prac- 
ticed resection  of  the  anterior  face  of  the  antrum  and  the  nasal 
process  of  the  superior  maxillary  bone,  for  the  purpose  of  reach- 
ing growths  in  the  nose,  throat  or  antrum.  To  expose  the  part 
to  be  resected,  he  makes  a  cut  alongside  of  the  nose  down  through 
the  lip:  and  a  second  cut  is  to  be  made  horizontally  from  the 
angle  of  the  mouth  to  the  masseter  muscle;  or  the  vertical  cut 
may  be  shorter  and  only  reach  from  the  ala  of  the  nose  to  the 
mouth,  the  horizontal  one  meanwhile  being  carried  to  the  mas- 
seter muscle.  After  such  operation,  Demarquay  thinks  that  the 
resected   bone  may  be  reproduced. 

In  concluding  this  chapter  on  resection  of  the  maxilla  supe- 
rior, the  writer  will  add  that,  from  his  operative  experience,  he 
has  learned  that  partial  excision  may  be  done  through  the  mouth, 
and  that,  for  total  unilateral  removal,  the  work  can  also  be  done 
by  widening  the  mouth  horizontally,  through  incising  the  bucci- 
nator muscle.  Such  cut  can  afterwards  be  closed.  Thus  proceed- 
ing, facial  pals}^  will  be  avoided,  and  facial  scarring  and  deform- 
itv  reduced  to  a  minimum. 


CHAPTER  XVI. 


MOUTH  AND  ORAL  CAVITY. 


Lips. — The  lips,  which  constitute  the  entrance  to  the  buccal 
cavity,  may,  within  normal  limits,  vary  much  in  shape  and  vol- 
ume, and  so  the  opening  which  the  lips  bound,  commonly  desig- 
nated the  mouth,  may  be  small  or  large.  The  dimensions  of 
this  opening,  when  large,  give  the  surgeon  an  advantage  when 
he  operates  in  the  buccal  cavity;  on  the  contrary,  the  smallness 
of  the  opening  may  be  such  that  it  requires  widening  by  incision, 
as  a  preliminary  to  intra-oral  work. 

The  investing  coverings  of  the  internal  and  external  surface 
of  the  body  meet  on  the  lips;  here  one  sees  a  transition  from 
mucous  membrane  to  derm  taking  place  so  gradually  that  the 
boundaries  between  the  two  are  indeterminable.  The  mucous  as 
well  as  the  dermo-mucous  coat  is  normally  of  red  color.  This 
hue  varies  in  different  subjects,  and  it  may  do  so  in  the  same 
person  at  different  times.  In  persons  of  the  sanguine  tempera- 
ment, and  in  those  addicted  to  spirituous  potations,  the  lips  are 
strikingly  red.  In  those  who  have  lost  much  blood,  and  in  the 
leucfemic  subject,  the  lips  are  pale.  And  the  li^^s,  which  are 
normally  red,  in  the  act  of  swooning,  become  pale;  a  condition 
frequently  supervening  in  those  to  whom  an  anaesthetic  is  being 
given;  such  paleness  then,  as  a  faithful  sentinel,  announces 
depressing  nausea  or  commencing  sj'ncope.  The  fading  color  of 
the  lips  demands  temporary  suspension  of  the  work,  during  a 
surgical  operation,  and  momentary  attention  to  the  condition  of 
the  patient.  Concealed  htemorrhage  is  indicated  by  the  colorless 
lip:  for  example,  when  blood  has  escaped  unseen  down  the 
throat  into  the  stomach,  or  in  work  done  on  tlie  rectum  the 
blood  has  passed  upwards  into  the  bowel;  and,  lastly,  such  pale- 
ness has  given  warning  of  intra-abdominal  hfemorrhage  which 
had  occurred  unseen  after  a  laparotomy.  Therefore,  attention  to 
the  color  of  the  lips  must  be  among  those  matters  which  demand 
care  in  the  surgeon's  work.  Such  paleness  is  the  silent  monitor 
(544) 


LIPS.  545 

of  present  or  impending  danger;  if  unheeded,  the  case  in  question 
will  probably  afterwards  stand  in  the  fatal  column  of  non-success, 
and  the  cause  of  death  be  placed  under  the  convenient  heading 
of  shock. 

Lying  between  the  mucous  and  dermal  coats  of  the  lips,  there 
exist  a  small  amount  of  adipose  tissue,  a  circular  muscle,  a 
glandular  stratum,  vessels,  lymphatics  and  nerves. 

The  fatty  tissue,  different  from  what  one  sees  elsewhere  near 
the  surface  of  the  body,  does  not  occur  as  a  sejjarate  layer;  the 
derm  and  mucous  membrane  are  closely  adherent  to  the  orbicular 
muscle,  and  the  adipose  material  is  diffused  through  the  muscle 
in  small  rounded  masses:  and  it  does  not  augment  in  amount; 
hence  the  lip,  like  the  eyelid,  does  not  increase  in  thickness 
through  adipose  development. 

The  oj)enings  of  the  eye,  ear,  nose  and  mouth  contain  muscu- 
lar fibers;  yet  the  openings  of  all  except  the  mouth  are  main- 
tained patent  by  a  layer  of  cartilage  in  their  walls;  such  stiffening 
material  is  absent  from  the  lips,  which  are  distinguished  by 
their  pliant  mobility;  and  any  surgical  work,  which  lessens  this 
suppleness  through  interjection  of  cicatricial  tissue  into  the  muscle, 
must  trammel  the  functional  activity  of  the  lips. 

The  various  facial  muscles  which  converge  towards  the  moutli 
aid  in  the  formation  of  the  orbicular  muscle,  those  from  above 
entering  the  lower  segment,  and  those  from  below  add  fibres  to 
the  upper  segment,  while  the  buccinator  contributes  fibres  to  both 
segments;  the  arrangement  being  such  that  the  mutually  inter- 
lacing bands  support  each  other  in  the  closure  of  the  mouth. 
The  entrance  and  action  of  these  comjoonent  muscles  at  the 
labial  commissure  give  transverse  elongation  to  the  oral  open- 
ing, in  opposition  to  the  independent  circular  fibres,  which  form  a 
considerable  part  of  the  orbicularis;  and  these  fibres  retracting 
cause  a  triangular  gap  when  the  lip  is  incised  vertically.  The  or- 
bicular muscle  is  closely  and  tightly  bound  to  the  skin  by  fibrous 
tissue.  In  unilateral  palsy  of  the  face,  the  mouth  is  drawn 
towards  the  unaffected  side;  and  in  bilateral  palsy,  as  seen  in  the 
apoplectic  patient,  the  lips  in  breathing  are  passively  drawn  in 
and  out,  as  in  the  act  of  smoking  the  pipe.  Also  in  the  non- 
palsied  face,  if  from  some  cause  there  be  greater  power  on  one 
side,  the  angle  of  the  mouth  will  incline  to  that  side,  and  give 
an  unnatural  expression.  In  unilateral  palsy,  the  depression  of 
the  labial  angle  permits  fluids,  which  are  received  in  the  buccal 
cavity,  to   escape   there,  much   to    the   patient's   inconvenience. 


546  MOUTH  AND  ORAL  CAVITY. 

And  a  similar  condition  is  induced  when  the  muscular  equipoise 
of  the  two  sides  of  the  face  is  disturbed  by  some  accidental  lesion, 
or,  perha2)s,  by  the  surgeon's  knife. 

A  no  less  important  structure  tlian  the  muscular  is  that  of 
the  glands,  which  lie  between  the  mucous  and  nmseular  coats. 
These  glands  are  in  greater  number  in  the  upper  than  in  the 
lower  lip,  yet  they  are  more  voluminous  in  the  lower  lip.  They 
are  surrounded  by  connective  tissue,  and  the  elements  for  suppu- 
rative action  are  here  present. 

These  glands,  hard  in  texture,  can  be  distinguished  when  the 
lip  is  pressed  between  the  thumb  and  finger;  likewise,  when  a 
section  is  made  through  the  lip,  as  in  the  excision  of  epitheli- 
oma, these  glands  crop  out  above  the  cut  surface,  and  should  not 
be  mistaken  for  diseased  tissue.  Should  the  uplifted  glands  ren- 
der the  surfaces  uneven  which  are  to  be  united,  they  should  be 
excised  with  scissors,  or  tlie  ])oint  of  the  scalpel. 

The  arteries  of  the  lip  are  derived  from  the  facial;  they  are 
the  superior  and  inferior  coronaries  and  the  inferior  labial.  These 
vessels  from  the  two  sides  inosculate.  Their  situation  in  the  lip 
is  important  to  note:  tlie  superior  and  inferior  coronaries  lie  in 
the  glandular  structure,  between  the  mucous  and  muscular  strata; 
and  they  are  situated  about  midway  between  the  attached  and 
the  free  borders  of  the  lips.  At  the  labial  commissure,  a  thumb 
and  finger  can  grasp  the  edge  of  the  mouth  so  as  to  include  and 
compress  these  arteries;  or  flat-bladed,  clasping  forceps  can  do 
the  same;  such  luemo.static  clasps  were  used  by  Langenbeck 
in  his  operations  on  tl)e  lip.  These  vessels  seldom  demand 
ligation,  since  the  suture  closing  the  wound  can  also  include  the 
vessel;  but  since  the  coronary  vessels  lie  just  underneath  the 
mucous  coat,  the  suture,  to  be  effective,  must  transfix  the  entire 
thickness  of  the  lip.  The  inferior  labial  artery  lies  behind  the 
labio-mental  sulcus;  and  it  results  that  when  a  long  vertical  cut 
is  made  through  the  lower  lip,  there  is  bleeding  from  both  the 
coronary  and  the  inferior  labial  vessels.  Likewise,  where  the 
upper  lip  joins  the  septum  of  the  nose,  there  is  an  arterial  branch. 
The  labial  veins  may  be  disregarded  in  surgical  work. 

The  lymphatic  vessels  pass  to  glands  which  lie  above  the 
hyoid  bone  in  the  space  bounded  by  the  inferior  maxillary  arch. 
The  enlargement  of  these  glands,  in  case  of  e^rithelioma  of  the 
lips,  is  of  great  prognostic  significance,  and  nearly  always  means 
incurability. 

The  nerves  are  motor  and  sensory:  the  motor,  derived  from 


LIPS.  547 

the  facial  nerve,  is  distributed  to  the  orbicular  muscle;  the  sen- 
sory filaments  of  trigeminal  source  are  numerous  and  are  prin- 
cipally sent  to  the  mucous  and  glandular  strata  of  the  lips. 

If  one  examines  the  site  of  the  mouth  in  the  incipient  embryo, 
the  upper  lip  will  be  represented  by  three  germinal  buds  or  tuber- 
cles, while  the  lower  lip  is  indicated  by  two;  in  each  lip  these 
germinal  buds,  developing,  finally  coalesce,  and  b}^  their  fusion 
they  form  the  normal  lip;  such  development  and  fusion  nearly 
always  occur  in  the  lower  lip.  The  embryologist  Coste,  who 
studied  and  described  these  rudimentary  parts  of  the  embryo, 
named  the  middle  one  of  the  upper  lip  the  incisive  bud,  since  it 
contains  the  germs  of  the  incisor  teeth;  it  likewise  contains  the 
primary  elements  of  the  premaxillary  section  of  the  maxilla 
superior.  The  origin  of  hare-lip  has  been  referred  to  an  arrest  oi 
the  development  of  these  primary  components  of  the  upper  lip. 

The  mouth,  or  opening  bounded  by  the  lips,  is  an  all-important 
part  to  the  new-born  child,  since  it  is  the  entrance  to  the  canal 
of  nutrition ;  and  if  the  form  of  the  lips  is  in  some  waj'-  ab- 
normal, the  life  of  the  infant  is  compromised.  Such  abnor- 
mality may  be  present  in  the  form  of  atresia  or  entire  closure, 
stenosis,  wideness,  deviation  of  the  site  of  the  mouth,  adhesions, 
labial  hypertrophy,  labial  atrophy  and  hare-lip. 

Atresia,  or  complete  closure  of  the  mouth,  is  rarely  seen  in  the 
new-born;  while  nature  not  unfrequently  disregards  her  guiding 
model  in  fashioning  the  rectal  end  of  the  alimentary  canal,  as 
well  as  of  the  adjacent  orifices,  the  oj^enings  of  the  mouth,  nose, 
eyes  and  ears  rarely  apj)ear  closed.  The  history  of  such  cases, 
as  phenomenal  rarities,  is  to  be  found  in  the  annals  of  medicine, 
especially  in  the  olden  time,  when  myth  and  fabulous  statement 
found  place  and  credence  along  with  truth.  And,  for  this  rea- 
son, such  cases  occur  much  often er  among  the  writers  of  the 
eighteenth  than  of  the  nineteenth  century;  the  winnowing  hand 
of  criticism,  the  love  of  fact  undebased  with  inaccurac}^  and  the 
restive  intolerance  of  the  unauthenticated  and  marvelous,  which 
characterize  the  present  century,  have  greatly  lessened  the  num- 
ber of  statements  which  levy  the  tribute  of  credulit\'. 

Yet  eliminating  the  untrue  and  improbable,  a  small  number 
of  trustworthy  observations  of  congenital  oral  atresia  are  found 
recorded;  and  when  studied  they  present  themselves  in  two 
classes:  (1)  Atresia,  in  which,  not  only  the  mouth,  but  the  upper 
extremity  of  the  alimentary  canal  is  wholly  closed.  This  closure 
coincides  with  other  deformity;  according  to  Craveilhier,  it  coin- 


548  MOUTH    AND    ORAL    CAVITY. 

cides  with  the  teratological  type  of  the  cyclopeaii  monster.  (2) 
111  the  second  form,  the  atresia  is  confined  to  the  hibial  orifice, 
the  cavitv  of  the  mouth  otherwise  being  perfect.  Sucli  closure 
may  be  a  coalescence  of  the  entire  thickness  of  the  lips,  or  the 
union  may  be  tlirough  the  medium  of  a  web-like  film  similar 
to  that  seen  in  atresia  ani.  In  the  form  in  which  oral  closure 
is  associated  with  absence  of  the  buccal  and  pharyngeal  cavities, 
the  unfortunate  infant  is  in  a  condition  which  defies  legit- 
imate surgery;  concurrent  conditions  of  ill  form  conspire  to  end 
its  existence  before  it  would  perish  from  hunger.  But  where  the 
atresia  is  of  the  web  form  just  mentioned,  then  the  operation  is 
of  a  simple  nature,  and  consists  in  division  of  the  occluding  film; 
to  do  this,  let  a  tenaculum  be  fixed  in  the  thin  web,  and  the  lat- 
ter being  lifted  up,  the  little  cone  thus  formed  can  be  excised, 
and  thus  a  circular  opening  is  obtained,  through  which  one  blade 
of  a  pair  of  scissors  can  enter,  and  the  oral  orifice  be  reestablished. 
The  wound  thus  made  is  slight,  yet,  to  maintain  it  fully  patent, 
some  instrument  of  dilatation  should  daily  be  introduced;  as  such, 
dressing  forceps  may  be  used,  which,  when  withdrawn  with  open 
blades,  will  dilate. 

Incomplete  or  partial  atresia  of  the  mouth  may  appear  con- 
genitally,  or  it  may  arise  later  as  the  result  of  some  lesion  or  dis- 
ease; and  such  occlusion  may  vary  from  a  small  orifice  to  one 
deviating  but  little  from  normal  size.  As  a  congenital  condition, 
the  lips  may  be  soldered  direct!}^  together  on  each  side,  or  they 
may  be  united  by  means  of  a  web-like  film,  there  remaining  a 
small,  median  opening.  The  mouth  may  be  narrowed  by  grad- 
ual extension  forwards  of  one  or  both  commissures,  through 
ulcerative  action  and  subsequent  union  of  the  raw  borders;  and 
such  ulcerative  agency  may  arise  from  any  cause  wliich  destroys 
the  mucous  coat  of  the  lips:  viz.,  a  traumatic  lesion,  or  one  from 
fire,  or  an  escharotic,  as  an  acid  or  an  alkali.  And  in  cases  in 
which  such  injury  to  the  lip  has  occurred,  precaution  should  be 
taken  to  prevent  adherence  of  the  parts;  and  this  consists  in 
daily  separating  the  adherent  surfaces  and  interposing  some 
body  which  will  maintain  the  parts  asunder.  This  prophylactic 
task,  though  industriously  pursued,  is  rarely  satisfactorily  accom- 
plished; the  oral  opening  remains  narrower  than  it  was  origi- 
nally. 

Treatment  of  Partial  or  Complete  Atresia  of  the  Mouth. — In  cases 
in  which  the  atresia  is  partial,  and  there  is  an  opening  of  small 
dimensions,  the  condition  has  sometimes  been  allowed  to  remain 


ATRESIA    OF    THE    MOUTH.  549 

unoperated  on;  and  then  the  patient  has  been  fed  through  a 
funnel  and  tube;  or  a  beak-bearing  cup  has  served  the  purpose; 
or  the  nutrient  fluid  has  been  injected  into  the  mouth  with  a 
syringe.  As  a  palliative  procedure  to  maintain  the  small  open- 
ing patent,  occasional  dilatation  may  be  made  by  means  of  a 
sponge-tent,  or  other  expanding  agent.  Such  treatment  would 
rarely  be  continued  long;  its  inconveniences  would  erelong 
overcome  the  subject's  reluctance  to  a  more  rational  treatment, 
in  which  one  of  the  following  operative  plans  may  be  adopted: 

The  united  structures  were  'simply  divided  with  a  knife  by 
Amussat,  and  separation  maintained  by  means  of  lead  foil ;  this 
plan  was  pursued  by  Boyer  also;  in  spite  of  persistent  efl'ort,  the 
cicatrizing  force  seems  to  have  triumphed  over  that  of  the  sur- 
geon, and  but  slight  improvement  was  thus  obtained. 

A  better  plan  than  the  preceding  was  one  which  was  sug- 
gested by  the  custom  of  piercing  j)arts  of  the  body  and  establish- 
ing a  cicatrized  foramen  by  means  of  a  foreign  bod}^;  an  example 
of  this  is  the  introduction  of  a  ring  in  the  lobule  of  the  ear. 
Savagism,  from  which  such  mutilation  originated,  still  affords 
examples  of  a  perforation  of  the  cheek,  similar  to  that  which 
the  surgeon  may  use  to  restore  the  narrow  mouth  to  normal  size. 
The  Polynesian  native,  as  well  as  the  Indians  in  the  valley  of  the 
Amazon,  pierce  their  cheeks  and  lips  with  pieces  of  bamboo  or 
wood,  and  retain  the  foreign  body  in  site  until  scar  tissue  is 
formed  around  it,  and  thus  a  permanent  opening  is  established. 
Such  work  ma}^  be  imitated  in  the  case  of  the  narrow  mouth; 
and  after  the  formation  of  such  opening  at  the  site  of  the  desired 
commissure,  the  part  remaining  between  this  and  the  small  oral 
opening  may  be  severed.  "Taking  a  lesson  from  the  South  Sea 
savage,  the  surgeon  may  use  as  perforator  a  piece  of  bone,  which, 
having  pierced  the  cheek,  is  allowed  to  remain  in  place  until  the 
opening  is  permanently  established,  when,  unlike  the  savage  who 
lets  his  remain  in  site  as  an  ornament,  the  surgeon  removes  the 
body  and  divides  the  remaining  bridge.  This  method,  named  by 
the  French  Botoc,  from  the  Botocudos,  a  cheek-perforating  tribe, 
partakes  too  much  of  savagism  for  a  place  in  scientific  surgery, 
and  is  better  replaced  by  one  of  the  following  plans: — 

Serre,  of  Montpellier,  introduced  an  operation  in  which  incis- 
ions are  made  laterally  and  horizontally  from  the  existing  open- 
ing, and  then  the  mucous  membrane  and  the  derm  are  united  by 
silken  sutures  so  closely  applied  as  to  completely  close  the 
wounded  parts.     The  work  thus  done  is  followed  by  healing,  and 


550  MOUTH  AND  ORAL  CAVITY. 

a  proper  oral  opening  is  secured  to  the  patient.  The  writer 
would  suggest  the  use  of  the  metallic  instead  of  the  silken  suture 
for  closure  of  the  wound. 

A  second  ]»lan,  which  was  originated  by  Dieffenbach,  is  the 
immediate  formation  of  commissures  which  are  invested  with 
trans[)Osed  mucous  membrane,  so  that  the  constructed  angle 
remains  as  it  is  formed.  To  do  this  work,  from  the  existing  oral 
opening  incise  laterally  to  the  site  of  the  desired  commissure; 
and,  having  cut  through  the  skin,  excise  a  small  portion  of  the 
thickness  of  the  cheek,  leaving  only  the  mucous  membrane  intact 
at  the  bottom  of  the  sulcus.  Next,  from  the  unsevered  mucous 
memln-ane,  so  construct  a  flap  that  it  can  be  folded  outwards,  and 
joined  by  suture  to  the  skin.  In  case  the  mucous  membrane  is 
uusuited  to  form  this  commissural  flap,  then  the  adjacent  derm 
may  be  employed  for  this  purpose.  When  the  commit^sure  is  thus 
formed,  the  skin  and  mucous  membrane  may  be  united  over  the 
remaining  wound  of  the  divided  cheek,  tlius  combining  the 
methods  of  Serre.  and  Dieffenbach. 

In  case  the  atresia  has  resulted  from  some  cause  which  has 
produced  other  deforming  scars,  these  should  be  removed, 
loosened  or  otherwise  changed  as  the  case  demands ;  and  among 
the  means  which  can  be  used,  that  of  subscision  is  one  of  the 
best ;  by  means  of  a  tenotome,  introduced  beneath  the  skin  or 
nmcous  membrane,  the  contracted  bands  may  be  severed,  and 
irregularity  of  surface  lessened. 

3Iacrosfoma. — A  condition,  quite  the  o^jposite  of  the  one 
described,  is  that  of  extreme  wideness,  named  macrostoma;  this 
is  usually  of  congenital  origin,  though  it  can  arise  from  acci- 
dental lesion,  or  even  the  surgeon's  knife.  Congenital  wide  mouth 
originates  in  an  arrest,  or  standstill,  in  the  work  of  commissural 
fusion  of  the  two  lips  in  the  development  of  the  embryo.  Sucli 
defective  form  is  often  associated  wath  other  abnormal  conditions 
of  the  infantile  face.  Or  there  may  be  cephalic  deformity;  and 
these  concomitant  defects  are  usually  of  so  serious  a  nature  as  to 
destroy  the  subject's  life.  Should  the  infant  have  no  other 
deformity,  this  one  would  entail  from  birth  the  troublesome  con- 
dition of  constant  escape  of  saliva  from  the  mouth;  and  at  a  later 
period,  during  dentition,  the  teeth,  lacking  their  usual  wall-like 
support,  would  tend  to  diverge  outwards,  and,  cropping  out 
through  the  abnormal  gap,  they  would  become  useless,  and. 
besides,  add  much  to  the  unsightlincss  of  the  i"ace.  The  abnor- 
mally exposed  mucous  surfaces  readily  ulcerate,  and  add  a  con- 


MACROSTOMA.  551 

tingent  to  the  trouble.  Besides  this  type  of  macrostoma  there  are 
seen  less  grades  of  it ;  these  may  be  so  near  normal  limits  as  to 
demand  no  surgical  attention;  but  if  it  is  a  marked  deformity, 
then  surgical  intervention  is  proper.  Had  the  German  princess, 
who  was  nicknamed  Taschenmaul,  or  pocket-mouth,  had  her  mouth 
reconstructed  in  infancy  by  the  surgeon's  hand,  it  is  probable 
that  she  would  have  been  spared  this  ignoble  sobriquet. 

The  writer  has  seen  a  case  of  unilateral  macrostoma  which 
originated  from  mercurial  ptyalism.  This  was  not  an  infrequent 
cause  of  oral  and  buccal  devastation  in  the  early  part  of  this 
century,  when  calomel,  the  "white  eagle"  of  the  old  alchemists, 
soared  triumphantly  through  the  domain  of  therapeutics,  and, 
not  unfrequently,  in  its  destructive  swoops  made  prey  of  tooth, 
jaw,  lip  and  cheek.  Accumulated  experience  has  trained  the 
eagle,  falcon-like,  to  abide  in  more  purposive  circlets.  In  the  case 
mentioned,  the  young  man  when  an  infant  was  so  severely 
ptyalized  that  a  portion  of  his  cheek,  including  the  angle  of  the 
mouth,  sloughed  and  left  a  great  breach  in  the  wall  of  the  buccal 
cavity.  The  teeth  which  grew  on  that  side  diverged  outwards 
and  stood  more  nearly  horizontal  than  vertical.  The  saliva 
constantly  escaped.  This  breach,  an  inch  and  a  half  in  height 
and  two  and  a  half  inches  long,  was  closed  by  an  operation  in 
which  the  protruding  teeth  were  removed,  the  edges  of  the  breach 
made  raw  by  free  trimming,  and  then  a  large  inferior  flap  was 
constructed  from  the  cutaneous  and  subcutaneous  structures 
which  lay  beneath  the  opening.  As  the  uplifting  of  this  flap  left 
a  large  gap  on  the  upper  part  of  the  neck,  to  close  this  a  pedicled 
flap  was  raised  from  the  loose  derm  near  the  clavicle,  and  fixed  in 
the  place  whence  the  first  flap  was  taken.  The  open  space,  now 
remaining  above  the  clavicle,  was  closed  by  means  of  subcutaneous 
detachment  and  lateral  sliding  of  the  adjacent  derm.  The  flaps 
healed  by  primary  union,  and  the  patient's  appearance  was 
much  improved. 

Besides  sloughing  of  the  cheek  from  mercurial  abuse,  it  niay 
arise  from  noma,  of  which  the  writer  once  had  the  unfortunate 
privilege  of  seeing  a  number  of  cases';  this  was  in  a  ward  in  an 
emigrant  hospital  which  had  been  set  aside  for  children  affected 
with  scarlatina  and  measles.  The  disease  was  of  a  virulent  form, 
and  the  ward  was  not  ventilated.  The  noma  began  as  a  small 
black  point  in  the  midst  of  the  swollen  and  ashy  pale  cheek,  and 
soon  extended  until  it  occupied  the  surface  corresponding  to  the 
buccinator  muscle.     In  nearly  all  these  cases,  death  spared  these 


552  MOUTH    AND    ORAL    CAVITY. 

unfortunates  from  impending  deformity,  and  the  essays  of  repar- 
ative surgery. 

Treatment. — The  problem  of  lessening  the  mouth  is  an  easier 
one  than  that  of  enlarging  it.  The  task  consists  in  shifting  the 
commissure  anteriorly.  This  can  be  accomplished  by  paring  the 
opposite  margins  and  uniting  the  raw  surfaces  by  metallic  suture, 
and  then  immobilizing  the  parts  by  an  ap})ropriate  bandage.  The 
work  done  in  this  way  has  the  disadvantage  that  the  commissure 
is  an  acute  and  not  obtuse  angle.  To  remedy  this,  a  flap  of 
mucous  membrane  may  be  uplifted  from  the  border  of  the  upper 
lip,  behind  the  site  of  the  desired  connnissure;  this  flap,  a  half 
inch  long,  and  with  attachment  forwards  at  the  proposed  com- 
missure, is  to  be  folded  forwards,  and  sutured  to  the  ]"aw  surface 
below.  Thus  an  obtuse  angle  is  formed.  The  remainder  of  the 
wound  is  to  be  closed  by  sutures,  and  the  jiarts  rendei^ed  motion- 
less by  a  proper  appliance. 

Deviation  of  the  Oral  Opening. — There  may  be  deviation  of  a 
part  of  the  wall  of  the  month,  or  the  entire  oral  opening  may  be 
displaced.  Thus  from  a  burn  on  the  cheek,  or  any  cause  destroy- 
incr  the  structures  near  the  angle  of  the  mouth,  the  work  of  cicatri- 
zation  may  attract,  and  displace  the  commissure  towards  the  j)lace 
of  injury.  In  like  manner,  a  single  lip  may  be  eccentrically 
displaced  by  an  adjacent  cicatrix.  And,  on  a  more  extensive 
scale,  a  migrating  lupus -has,  in  its  cicatrizing  march,  drawn  along 
the  mouth  for  a  short  distance. 

Besides  the  causes  enumerated,  laljial  deviation,  extensive  or 
limited,  may  arise  from  osseous  disease  through  which  a  portion 
of  the  upper  or  lower  jaw  is  destroyed.  The  author  has  seen 
examples  of  each;  in  the  greater  numljer,  however,  the  disease 
was  in  the  maxilla  inferior,  and  in  children.  The  loss  of  a 
portion  of  the  lower  jaw  through  necrosis,  and  the  dwarfed 
development  of  the  jaw,  cause  the  chin  to  retreat,  and  the  teeth  of 
the  upper  jaw  to  project  forwards  and  slope  outwards.  And  if 
the  necrosis  be  unilateral,  the  mouth  will  sink,  and  its  angle  be 
deflected  towards  the  affected  side.  In  such  cases  the  upper 
incisors,  through  their  ill  position,  become  a  striking  deformity. 
Such  a  mouth  can  be  improved  in  form;  and  this  improvement 
will  be  greater  if  the  subject  be  a  child  whose  face  is  not  wholly 
developed.  This  work,  commonly  committed  to  the  hands  of  the 
dentist,  is  done  by  removing  a  canine  or  a  bicuspid  tooth  on  each 
side,  and  then  a  compressive  band  including  the  incisor  teeth  is 
fastened  to  the  teeth  behind.     Tims  the  projecting  teeth  can  be 


LABIAL    HYPERTROPHY.  553 

forced  backwards  into  the  space  left  by  the  extracted  teeth.  To 
be  effective,  this  compression  should  be  continued  for  a  year,  or 
even  longer.  In  bad  cases  it  may  be  necessary  to  extract  two 
teeth  on  each  side.  If  the  backward  pressure  be  made  with 
too  much  force,  in  order  to  shorten  the  period  of  treatment,  there 
is  the  risk  of  injuring  the  nerves  which  supply  the  shifted 
teeth;  the  latter,  like  other  j^arts  of  the  human  body,  will  revolt 
against  a  rapidly  encroaching  violence,  which  would  be  easily 
tolerated  if  it  approached  gradually.  Surgical  art,  as  far  as  is 
possible,  should  here  copy  the  methods  of  nature,  who  hastens  not, 
and  spurns  all  limitations  of  time  in  the  accomplishment  of  her 
work. 

In  cases  in  which  correction  of  the  deformity  cannot  be  satis- 
factorily effected  in  the  manner  above  described,  then,  after  the 
removal  of  lateral  teeth,  the  jaw  can  be  partially  divided  on 
each  side,  and  the  work  of  pressing  backwards  the  protruded 
portion  can  be  done,  as  before  pointed  out. 

Labial  Hypertrophy. — Hypertrophy  of  the  lip,  consisting  in  a 
thickening  of  the  mucous  membrane  and  of  the  submucous 
structure,  occurs  as  a  rare  deformity  of  the  mouth.  The  upper 
lip  is  more  often  the  site  of  the  enlargement;  it  does,  however, 
occur  in  the  lower  lip.  This  condition  is  named  double  lip,  and 
it  has  been  given  the  more  technical  name  of  exstrophy.  It 
consists  in  an  augmentation  of  the  components  of  the  mucous 
membrane  along  the  entire  visible  border  of  the  lip.  In  the  act 
of  smiling,  this  red  and  transversely  striated  structure,  moistened 
with  the  mucus,  which  its  enlarged  glands  secrete,  is  rolled  for- 
wards, and  gives  the  mouth  a  most  disagreeable  appearance.  A 
condition  present,  and  probably  having  some  causal  agency,  is 
defective  development  of  the  derm  which  adjoins  the  lip.  This 
is  said  to  exist  congenitally;  and  afterwards,  in  growth,  the 
mucous  structure  outstrips  the  dermal.  The  infant,  in  protruding 
its  tongue  against  the  lip,  aids  in  the  development.  Irritation  in 
the  form  of  slight  abrasion,  ulceration,  or  fissure,  promotes  the 
growth. 

Treatment. — Attempts  have  been  made  to  remove  this  condi- 
tion therapeutically;  astringents  have  been  applied  for  this 
purpose,  but  with  unsatisfactory  result.  The  more  rational  treat- 
ment is  excision,  which  may  be  done  by  grasping  horizontally  a 
fold  of  the  redundant  structure  and  excising  this  with  scalpel  or 
scissors.  A  transfixing  tenaculum  may  serve  to  uplift  the  part  to 
be  removed.  The  writer  once  treated  by  thermal  cauterization  a 
36 


554  MOUTH  AND  ORAL  CAVITY. 

case  in  which  the  upper  and  lower  lips  were  the  site  of  hypertro- 
phy, the  enlargement  being  mainly  in  the  lower  lip.  These 
greatly  enlarged  lips,  with  their  gelatinous  coating  of  inspissated 
mucus,  presented  a  most  repulsive  appearance.  The  derm  was 
not  defective,  as  it  usually  is  in  the  ordinary  case  of  double  lip. 
The  form  was  corrected  by  the  use  of  the  blade  point  of  the 
thermal  cautery.  The  muciparous  glands  were  much  enlarged. 
The  wound  made  was  allowed  to  heal,  by  granulation,  and 
the  result  was  a  reduction  to  something  near  normal  form.  In 
such  cases,  the  work  of  excision  might  be  done  with  the  knife 
with  less  peril  of  exceeding  the  proper  limit  of  retrenchment,  and 
after  the  surplus  structure  was  removed,  the  wound  could  be 
closed  by  sutures. 

Labial  Ectropion. — One  or  both  lips  may  be  everted  through 
ulceration  or  some  lesion  destroying  the  dermal  surface  near  the 
mouth.  The  most  common  cause  is  a  burn  arising  from  a  flame, 
exploding  powder,  or  an  acid  or  alkaline  escharotic.  The  cicatriz- 
ing surface  shortens  and  draws  the  adjoining  lip  outwards  and 
fixes  it  in  that  position.  The  resulting  deformity  is  great;  for 
example,  in  a  case  of  a  burn  from  flame  which  the  writer  saw, 
the  upper  lip  was  drawn  upwards  to  the  septum  of  the  nose,  and 
the  lower  lip  was  drawn  down  and  fastened  to  the  chin.  And, 
in  another  case,  along  with  such  labial  distortion,  the  chin 
was  drawn  down  and  held  near  the  larynx.  In  such  cases  the 
teeth  exposed  to  the  air  are  disfigured  by  incrustations  and 
inspissated  secretions  of  the  buccal  cavity.  The  saliva  trickles 
uncontrolled  from  the  mouth,  and  adds  to  the  patient's  unfortu- 
nate condition.  In  eating,  fluids  escape,  and  the  ingestion  of 
food  is  embarrassed,  since  the  mouth  cannot  be  closed,  as  is  neces- 
sary during  ordinary  deglutition.  For  relief  from  the  wretched 
plight  in  which  such  a  patient  finds  himself,  the  surgeon's  hand 
is  earnestly  appealed  to. 

As  means  to  correct  labial  eversion,  one  may  resort  to  the 
undulating  incisions  of  Dieffenbach,  the  V-cut  of  Weber,  or  to  the 
incisions  of  Teale. 

The  undulating  cut  of  Dieffenbach,  best  fitted  for  the  upper 
lip,  is  made  on  each  side  of  the  nose,  as  follows:  The  incisions 
closely  circumscribe  the  wings  of  the  nose,  and  are  continued 
downwards  convergently  on  the  lip,  and  meet  a  short  distance 
above  the  margin  of  the  lip;  the  incisions  unite  beneath  the  nasal 
septum  in  one  line,  which  is  continued  downwards  into  the 
mouth;  thus  two  flaps  are  formed  which  are  drawn  downwards 
and  united  bv  sutures. 


LABIUM    LEPORINUM.  555 

The  method  of  Weber,  of  which  he  acknowledges  the  sugges- 
tions from  Wharton  Jones,  consisted  in  making  a  V-incision, 
open  towards  the  mouth,  and  wlaich  includes  tlie  scar  tissue  that 
pulls  the  lip  outwards;  the  adjacent  parts  are  detached,  brought 
into  position,  and  retained  so  by  sutures.  Instead  of  opening 
towards  the  oral  opening,  the  writer  suggests  that  tiie  V-incisions 
might  converge  towards  the  mouth,  and  then  the  lateral  struc- 
tures being  loosened  might  be  rectified  in  position,  and  fixed 
thus  by  sutures  to  the  sustaining  and  retaining  angle  of  the  V- 
incision.  In  this  work,  should  the  mucous  border  be  too  promi- 
nent, a  horizontal  section,  oval  in  form,  may  be  removed  from  it. 

A  third  method  by  which  the  lip,  everted  and  shortened  in 
height,  can  be  improved  in  form,  is  that  proposed  by  Teale,  which 
is  as  follows:  For  the  lower  lip,  when  ectropic,  let  there  be  made 
two  incisions  downwards  through  its  entire  thickness;  and  these 
cuts  are  at  sucli  a  distance  from  each  other  as  to  include  one-half 
of  the  lip  between  them.  Next,  from  the  lower  ends  of  each  of 
these  cuts,  an  incision  is  to  be  made  upwards  and  obliquely  out- 
wards, and  end  one  inch  beyond  the  labial  commissure.  Now 
let  the  uj)per  border  of  the  intermediate  portion  be  made  raw  by 
trimming;  and,  finally,  the  lateral,  detached  flaps  are  to  be  drawn 
inwards  and  fastened  on  and  above  the  upright  intermediate 
portion.     In  this  way  the  lip  is  rectified  in  position. 

Hare-lip,  Cleft-lip,  Labium  Leporinum. — Cleft-lip,  or  hare -lip,  as 
it  is  popularly  named,  is  one  of  the  most  interesting  subjects  to 
the  operative  surgeon ;  he  has  an  assured  and  undisputed  posi- 
tion here,  since  surgical  art  has  no  envious  rival  in  the  means 
for  the  relief  of  this  defect;  and  the  surgeon's  hand  dan  never  be 
superseded  by  that  of  the  presumptuous  charlatan.  Nature, 
whose  unseen  work  is  often  usurped  or  stolen  by  cunning  igno- 
rance, is  helpless  here,  and  pleads  for  intelligent  aid;  and  the 
interesting  myth  invented  to  explain  the  incomplete  model  of 
the  cathedral  at  Cologne  is  here  repeated;  the  envious  fiend  of 
Ill-form  seems  to  have  snatched  from  the  hand  of  nature  the 
archetypal  design  of  her  purposed  structure;  and  nothing  short 
of  a  Saint  Ursula  typified  in  the  wonder-doing  hand  of  the 
trained  surgeon,  can  restore  the  lost  sketch  and  bring  back  again 
to  normal  form  the  marred  face.  To  learn  how  nature  may 
wander  from  her  wonted  well-beaten  path  in  her  work  of  model- 
ing the  human  face,  some  light  is  gotten  by  a  study  of  the 
metamorphic  stages  through  which  the  embryonic  face  passes 
in  its  primeval  development. 


556 


MOUTH    AND    ORAL    CAVITY. 


The  changes  of  form  which  the  embryo  undergoes  have  been 
carefully  studied  by  Coste,  His,  Reichert,  Thompson  and  others. 
At  the  age  of  one  month,  the  human  embryo  has  the  form  of  a 
semi-circle  or  letter  C;  and  the  cej^halic  end  presents  an  enlarge- 
ment corresponding  to  the  future  head.  On  the  inner  side  of  this 
enlargement,  transverse  arches,  named  branchial  or  gill-arches, 
are  seen;  and  between  these  arches  lie  intermediate  clefts,  or 
openings,  as  exhibited  in  Figure  76.     A  shows  the  head  at  one 


o-~z 


^     S 

Figure  76.     Plates  from  Von  Amraon  showing  development  of  the  foetal 
head. 

month,  and  B  exhibits  a  later  stage  when  the  frontal  plate  n,  the 
lower  lip  u  and  the  eyes  oo  are  appearing.  '  The  uppermost  cleft 
is  the  one  to  which  the  most  interest  attaches,  since  it  occupies 
the  site  of  the  future  mouth ;  and  if  the  surroundings  of  this 
fossa  be  observed,  one  finds  that  it  has  overhanging  it  a  small 
structural  plate,  named  from  its  position  the  frontal  lamella;  on 
the  opposite  side  lies  the  part  which  corresponds  to  the  inferior 
maxilla,  or  lower  boundary  of  the  mouth.  At  the  upper  part  of 
the  sides  of  the  fossa  are  the  germinal  buds  of  the  future  upper 
jaw,  which  are  some  distance  apart;  and  as  development  pro- 
ceeds, beneatli  the  frontal  plate  on  each  side  exists  a  small 
depression,  bounded  internally  and  externally  by  the  nasal  buds. 
As  growth  continues,  the  lateral  maxillary  processes  approach  each 
other;  and  the  intermediate  naso-frontal  plate  grows  downwards, 
and  is  named  from  its  position  the  incisive  plate.  These  parts, 
in  the  normal  face,  continue  to  enlarge  by  growth,  until  the 
incisive  and  lateral  maxillary  processes  unite  and  close  the 
irregular  gap,  which  overhangs  the  embryonic  oral  opening;  the 
fusion  is  so  complete  that  in  the  normal  adult  all  traces  of  the 
primitive  fissures  have  vanished.  Reverting  to  the  rudimentary 
bars  w^hich  cross  the  inner  face  of  the  forming  head,  it  is  seen 
that,  at  an  early  period,  the  upper  one  may  be  likened  to  a  broken 
arch,  which  is  constituted  of  a  middle  and  two  lateral  segments, 


LABIUM    LEPORIXUM.  557 

SO  disposed  that  an  upright  cleft  exists  on  each  side. "  Normally, 
as  said,  these  clefts  vanish;  abnormally,  one  of  them  continues, 
and  then  an  opening  remains,  which,  if  limited  to  the  lip,  consti- 
tutes a  single  hare-lijD;  or  if  the  fissure  extends  deeper  and  more 
posteriorly,  then  the  case  is  one  of  labio-palatal  cleft.  The 
defective  development  seems  to  be  more  concerned  in  retarded 
growth  of  the  intermediate  plate;  and  if  this  part  be  followed  in 
its  growth,  it  is  found  that  there  originate  from  it  the  frontal 
bone,  the  nose,  the  vomer  and  the  intermaxillary,  named  also  the 
incisive  bone;  and  the  retarded  growth  is  principally  in  the 
lateral  faces  of  the  intermaxillary  bone  and  the  lip  in  front  of  this 
bone. 

It  was  reserved  for  the  inventive  fancy  of  the  chief  of  German 
poets  to  catch  the  first  glimpse  of  the  doctrine  that  hare-lip  is 
the  result  of  arrested  development.  Goethe,  whose  mind  created 
the  imperishable  imagery  of  Faust,  revealed,  as  Virchow  says,  his 
nobility  in  that  he  sought  mental  invigoration  in  the  obser- 
vation and  study  of  material  objects  and  material  phenomena, 
and  found  content  in  the  "eternally  true."  Blumenbach,  the  con- 
temporary of  Goethe,  whose  museum  of  crania  at  Gottingen  still 
rivals  any  European  collection,  taught  the  same  doctrine. 
Meckel,  Beclard  and  Geoffroy  Saint  Hilaire  espoused  the  same  doc- 
trine. And  the  theory  was  elucidated  and  verified  by  the  studies 
of  Coste,  who  found  that  the  early  forms  of  the  embryo  are  in 
accord  with  such  theory.  The  conclusions  arrived  at  from  these 
studies  are,  according  to  Sappey,  that  hare-lip  is  caused  by  an 
arrest  of  development;  that  this  arrest  affects  chiefly  those  parts 
of  which  the  development  is  tard}^;  and  that  when  the  arrest  is 
present  in  other  parts  of  the  body,  the  deformity  of  the  mouth 
is  usually  the  greatest;  also  the  arrest  appears  simultaneously  in 
both  the  soft  and  hard  structures;  and  finally,  that  such  arrest 
results  from  some  natural  cause,  at  present  unknown. 

Those  who  have  been  occupied  in  researches  upon  this  subject 
concede  that  causes  other  than  arrested  development  may  be 
present,  and  cooperate  or  be  the  chief  agent  in  the  matter. 

Among  agencies  which  have  been  suggested  as  causes  of  hare- 
lip, the  following  maybe  mentioned:  Heredity,  in  which  some- 
thing abnormal  is  impressed  on  the  primordial  germs,  disease 
affecting  the  foetus,  maternal  impressions  acting  on  the  foetus, 
and  mechanical  causes,  as  adhesions  of  the  foetus  to  its  cord  or 
membranes. 

That  heredity  has  a  bearing  is  shown   by  the  fact,  that  in 


558  MOUTH  AND  ORAL  CAVITY. 

certain  families  liare-lip  lias  been  transmitted  through  successive 
generations;  the  anomaly  in  the  first  instance  being  due  to  the 
law  of  variation,  which  is  observed  to  particularize  the  form  of 
members  of  the  same  species. 

Observation  of  the  new-born  has  shown  tliat  intra-uterine 
life  has  its  diseases;  and  if  some  affection  were  to  implicate  the 
region  of  the  branchial  arches  and  clefts,  these  parts  might  cease 
their  growth,  and  deformity  result.  The  origin  of  hare-lip  has 
been  referred  to  mechanical  causation,  in  wliich  some  agent,  as 
the  hand,  cord,  or  other  member  or  appendage  of  the  embryo, 
ma_y  rest  against  the  oral  region  and  interfere  with  its  proper 
growth. 

Popular  opinion  assigns  to  the  mother's  mind  an  important 
agency  in  the  causation  of  hare-lip.  Dionis,  Roux  and  Langen- 
beck  have  given  credence  to  such  agenc}'.  After  an  apologetic 
prologue  for  the  avowal  of  his  belief,  Roux  says:  "Since  some 
time,  I  admit  the  empire  of  the  mother's  mind  upon  her  foetus; 
and  this  power  seems  to  be  greater  in  prof)ortion  as  the  foetus  is 
more  removed  from  its  complete  term  of  development;  I  believe 
that  great  mental  shocks,  and  vivid  impressions  acting  on  the 
pregnant  woman,  can  probably  cause  naevi,  and,  especially, 
striking  deformities  and  freaks  of  nature;  and  such  agency 
might  cause  disturbance  of  nutrition,  and  change  the  order  of 
evolution,  and  development  of  the  organs."  In  a  clinical  lecture 
of  B.  Langenbeck,  heard  by  the  writer,  the  learned  professor  in  a 
manner  half  reluctant  and  apologetic,  avowed  his  credence  in 
the  influence  of  maternal  impressions  in  producing  deformity  in 
offspring;  his  remarks  were  a  preface  to  an  operation  in  a  patient 
of  hare-lip;  and  a  few  cases  within  his  own  experience  were 
cited  in  proof  of  such  agency.  As  counter  evidence  against 
such  agency,  the  author  would  state  that,  in  an  extended  experi- 
ence, he  has  met  many  women  who,  from  some  ill  adventure,  had 
had  ample  reason  to  anticijiate  such  "mark"  in  their  offspring, 
but  the  latter,  at  birth,  were  free  from  any  deformity;  and,  hence, 
such  agency  lies  within  the  domain  of  chance  where  "millions 
miss  for  one  that  hits." 

If  such  agency  ever  obtains,  the  impression  could  only  be 
made  during  the  first  few  weeks  of  gestation;  that  is,  during  the 
inceptive  stage  of  development,  while  the  miniature  embryo  lies 
in  contact  with  the  uterine  wall,  and  may  be  conceived  to  be  in 
contact  with  the  ending  of  the  uterine  nerves;  but,  at  a  later 
period,  the  separation  of  the  embryo  from  the  wall  of  the  womb, 


LABIUM    LEPORINUM.  559 

and  the  intervention  of  tbe  nerveless  funis,  preclude  any  com- 
munication between  the  mother  and  foetus  through  the  medium 
of  nerve  roots.  This  fact  may  be  offered  as  solace  to  expectant 
mothers,  who  can  be  assured  that  after  three  months  there  exists 
an  impassable  breach  athwart  which  their  imaginations  cannot 
wander  to  the  detriment  of  their  offspring,  which  is  yet  in  plastic 
state. 

The  causal  agency  of  retardation  of  development  has  been 
referred  by  some  to  the  nerves  of  the  foetus,  yet  most  authorities 
find  the  proximate  agency  in  insufficient  vascular  supply  of  the 
affected  parts;  with  our  present  knowledge  the  more  rational 
theory  is  defective  supply  of  blood.  New  development  is  natu- 
rally the  sequent  of  vascular  growth;  since  the  blood  is  the 
pioneer  agent  of  all  organization.  And  in  inadequate  vascu- 
larity may  likewise  be  found  the  probable  reason  of  the  usual 
occurrence  of  the  hare-lip  on  the  left  side,  instead  of  on  the 
right;  and  the  defect  finds  its  reciprocal  correlate  in  right- 
handedness,  of  which  the  most  satisfactory  explanation  is  that 
of  Hyrtl,  viz.,  that  there  is  more  blood  sent  to  the  right  side 
than  the  left. 

The  supply  of  blood  to  the  parts  that  become  the  site  of  hare- 
lip is  through  the  facial,  transverse  facial,  the  internal  maxillary 
branches  of  the  external  carotid  artery  and  the  infra-orbital 
branch  of  the  internal  carotid  artery.  These  branches  are  like 
the  ribs  along  which  constructive  material  is  carried  to  the 
border  of  the  leaf;  and  if  the  arteries  are  obstructed,  the  parts 
supplied  become  dwarfed  in  the  same  way  as  the  border  of  the 
leaf  is  imperfect  when  its  nutrient  channels  are  obstructed.  *In 
what  way  the  vessels  of  suj)ply  may  be  obstructed  has  not  yet 
been  determined ;  the  author  will  suggest  that  it  may  be  explained 
conjecturally  by  flexion  and  position  of  the  developing  embryo, 
for  example:  Abnormal  flexion  of  the  arterial  channels  may 
lessen  the  blood  supply,  and  restrain  growth.  Also,  from  obliq- 
uity of  direction,  in  either  the  cephalic  or  podalic  presentation 
the  blood-pressure  may  be  unequally  distributed,  and  the  scales 
of  nutrition  becoming  unbalanced,  there  is  an  uneven  or  one- 
sided distribution  of  constructive  material. 

Children  occasionally  present  at  birth,  lips  and  roof  of  the 
mouth  marked  as  if  they  had  recently  recovered  from  an  opera- 
tion for  the  cure  of  cleft  lip  and  palate;  and  such  vestiges  of 
cicatrization  are  explained  by  the  supposition  that  there  has 
been  retarded  closure  of  the  fcetal  clefts.     Max  Bartels,  in  1873, 


560  MOUTH    AND    ORAL    CAVITY. 

published  observations  on  the  subject  of  closure  of  the  hare-lip 
in  the  uterus.  In  one  case  there  was  a  scar  of  a  cleft  which  had 
healed  on  one  side  of  the  lip ;  and,  in  a  second  child,  there  was  a 
scar  on  both  the  right  and  left  sides  of  the  lip,  which  seemed  to 
be  remnants  of  healed  clefts.  Rcnnes,  Dieudonne,  Marjolin  and 
Desormeaux  believe  that  such  intra-uterine  closure  may  occur. 
Bruns  thinks  such  labial  scar  is  the  mark  remaining  of  a  cleft 
which  extended  through  the  palatal  vault,  upper  jaw  and  lip. 
The  author  has  a  case  under  observation,  in  which  there  is  the 
plain  mark  of  a  lately  healed  median  cleft  on  the  upper  lip  of  an 
infant,  in  which  the  burden  of  deformity  is  widespread,  having 
been  laid  in  the  arms,  hands,  fingers,  legs  and  feet  of  the 
unfortunate  child.  Probability  is  lent  to  this  theory  of  late 
closure  by  the  fact  that  cases  have  been  observed  in  which  the 
closure  occurred  after  the  birth  of  the  child.  The  so-called  intra- 
uterine cicatrization  is  hereditary  in  certain  families.  It  is 
reported  to  have  been  seen  in  children,  the  offspring  of  parents 
who  were  the  subjects  of  hare-lip.  Instead  of  closure  having 
occurred  as  here  indicated,  may  not  the  appearance  have  arisen 
from  the  parts  having  fused  in  an  unnatural  manner,  in  which 
the  supra  oral  tripartite  components  of  the  face  met  and  fused 
irregularly,  nature  here  doing  her  work  in  the  thoughtless  way 
of  a  surgeon  who  closes  unevenly  the  lips  of  an  incised  wound, 
or  badly  coaptates  in  the  repair  of  a  labial  cleft? 

A  nearly  forgotten  theory  of  hare-lip  is  that,  after  the  parts 
have  been  normally  formed,  they,  afterwards,  through  atrophy, 
separate,  and  leave  clefts;  such  a  theory  is  irrational,  and  in 
discord  with  tlie  rules  and  method  to  which  nature  conforms  in 
the  work  of  organization. 

Hare-lip  presents  itself  in  several  forms,  wliicli  may  be  clas- 
sified as  follows: — 

1.  Simple  lateral  hare-lip. 

2.  Simple  lateral  hare-lip  with  complications. 

3.  Uncomplicated  double  hare-lip. 

4.  Complicated  double  liare-lip. 

5.  Median  hare-lip  of  the  upper  lip. 

6.  Median  hare-lip  of  the  lower  lip. 

1.  Simple  uncomplicated  hare-lip  is  usually  situated  on  the 
left  side :  it  consists  of  a  cleft  with  separation  of  the  borders, 
having  the  form  of  an  inverted  Y.  The  borders  have  the  red 
lining  of  the  normal  lip;  when  the  infant  cries,  the  borders  sep- 
arate, and  the  gap  becomes  larger;   and  closure  of  the  mouth 


LABIUM    LEPOEIXUil.  561 

brings  the  borders  towards  each  other.  This  cleft  in  different 
subjects  varies  in  degree,  from  a  minute  gap  in  the  border  of  the 
lip  to  a  breach  which  reaches  from  the  border  of  the  lip  to  the 
lower  border  of  the  left  nostril. 

2.  The  simple  cleft  may  present  various  complications,  of 
which  the  following  may  be  mentioned:  The  opposite  borders  of 
the  cleft  may  be  of  unequal  thickness;  and  in  that  case,  the  left 
side  is  commonly  thinner  than  the  right  one.  In  cases  in  which 
there  is  claimed  to  have  been  retarded  union,  the  united  portion 
is  often  thinner  than  the  adjacent  structure  of  the  lip.  In  the 
so-named  retarded  union,  the  closure  may  be  yet  more  imperfect, 
viz.,  there  may  be  an  angular  opening  at  the  nostril  and  at  the 
border  of  the  lip,  the  apices  of  which  are  directed  towards  each 
other,  and  are  separated  by  a  longer  or  shorter  bridge  of  atten- 
uated structure.  Likewise,  in  the  maxilla  just  behind,  there  may 
be  a  depression  denoting  late  union ;  or  perhaps  there  is  irregular 
closure  of  the  lateral  premaxillary  suture.  The  labial  hare-lip 
may  be  coincident  with  palatal  fissure,  which  may  be  minute  or 
of  vast  dimensions.  A  frequent  complication  of  labial  cleft  is  its 
extension  into  the  left  nostril ;  and  then  the  nostril  is  much  too 
wide,  and  the  left  wing  of  the  nose  is  inclined  oblic|uely,  and 
adds  to  the  deformity. 

3.  In  the  double  uncomplicated  harelip,  there  exist  two  clefts 
of  inverted  Y-shajDe,  separated  by  a  triangular  portion  of  the  lip, 
which  lies  over  the  incisor  teeth.  These  two  fissures,  with  the 
intermediate  angular  portion  of  the  lip,  when  Anewed  together 
present  the  appearance  of  an  inverted  M.  The  median  remnant 
may  be  regular  or  irregular  in  outline,  and  thinner  or  thicker 
than  the  lateral  boundaries  of  the  defect.  Palatal  cleft  is  often 
associated  with  the  double  cleft ;  and  in  great  variety  of  form, 
this  concurrent  defect  may  complicate  and  increase  the  labial 
deformity.  AVhen  palatal  cleft  exists,  the  premaxillary  bone 
may  be  lessened  in  volume,  and  occupy  an  abnormal  position: 
viz.,  the  palatal  gap  on  one  side,  or  those  on  both  sides,  are  formed 
at  the  expense  of  the  side  or  sides  of  the  bone;  in  fact,  the  open 
breach  may  c[uite  occupy  the  premaxillary  space;  more  often, 
however,  there  exists  a  fragment  of  the  bone;  and  then,  as  a  con- 
tinuation of  the  vomer,  in  smaller  or  greater  volume  it  hangs 
promontory-like,  over  the  oral  cavity;  and  if  the  subject  has 
reached  adult  age  without  being  operated  on,  the  protruded  bone, 
armed  with  teeth,  becomes  a  revolting  and  most  intolerable  deform- 
ity.    No  surgical  ailment  makes  stronger  appeals  for  operative 


562  MOUTH    AND    ORAL    CAVITY. 

aid;  and  in  scarcely  any  deformity  of  the  body  can  intelligent 
skill  make  greater  improvement  than  in  this  one. 

Besides  the  usual  forms  of  hare-lip  before  mentioned,  there 
remain  to  be  referred  to,  certain  unusual  forms,  placed  in  our 
classification  under  heads  three  and  four. 

Bidalot,  in  1867,  wrote  on  rare  and  unusual  forms  of  hare-lip; 
he  makes  four  groups  of  these  rare  cases :  (1)  Cleft  of  the  upper 
lip  extending  upwards  to  the  lower  eyelid,  (2)  Median  cleft  of 
the  upper  lip.  (3)  Median  cleft  of  the  lower  lip.  (4)  Horizontal 
hare-lip.  Michel  saw  an  example  of  the  first  kind.  In  1855, 
Parise  of  Lille  saw  an  infant  in  which  there  was  a  median  cleft 
in  the  lower  lip ;  the  sides  of  the  opening  were  lined  with  mucous 
membrane  and  stood  asunder  as  in  normal  hare-lip.  The  tongue 
was  bifid;  also  the  lower  jaw  was  cleft  anteriorly,  and  the  halves 
united  by  fibrous  tissue.  The  child  lived  but  one  month  ;  yet  its 
remarkable  deformities  assure  it  a  lasting  paragrapli  in  the 
annals  of  surgery. 

In  1870,  Tr^lat  reported  a  case  of  median  cleft  in  the  lower 
lip,  seen  byoneRibell;  this  fissure  extended  down  to  the  chin. 
In  1879,  Lannelongue  reported  two  cases  of  congenital  cleft  of  the 
lower  lip;  in  one  case  the  fissure  extended  into  the  lower  jaw,  so 
that  the  two  halves  were  movable,  one  on  the  other.  The  child, 
two  and  a  half  years  old,  had  been  operated  on  with  but  partial 
closure  of  the  cleft;  the  saliva  escaped  through  the  unclosed  por- 
tion. And,  in  another  case,  in  a  girl  fourteen  years  old  who  had 
club-foot,  and  hare-lip  in  the  ujtper  lip,  tliere  existed  a  transverse 
fissure  in  the  lower  lip,  a  half  incli  long  and  two-fifths  of  an  incli 
deep;  tliis  fissure  was  beneath,  and  parallel  with  the  border  of 
the  lower  lip;  and  was  closed  by  an  operation. 

Morian,  in  1886,  writing  on  the  irregularities  which  hare-lip 
or  facial  clefts  may  present,  finds  three  varieties:  (1)  The  cleft 
commencing  as  a  hare-lip,  ascends  between  the  nose  and  the 
cheek  to  the  inner  angle  of  the  eye,  and  thence  passes  out  through 
the  outer  canthus,  and  extends  upwards  on  the  forehead.  (2) 
The  cleft  may  commence  more  externally  than  the  preceding 
species,  and  ascending  outside  of  the  wing  of  the  nose  to  the 
inner  canthus,  it  pursues  the  same  course  as  the  preceding  one. 
(3)  The  slit  commences  at  the  angle  of  the  mouth  and,  ascending, 
enters  the  palpebral  slit.  Other  writers,  as  Blandin,  Bitot  and 
Xicati,  have  written  on  median  cleft  of  the  upper  lip.  And  if  the 
records  of  teratology  were  searched  by  some  tireless  compiler  or 
statistician,  other  examples  of  irregularity  in  labial  cleft  might 
be  found. 


LABIUM    LEPOEIXUM.  563 

Among  the  numerous  agencies  which  are  inimical  to  infantile 
life,  hare-lip  deserves  a  prominent  place;  and  this  danger  is 
greater  in  proportion  as  the  disease  is  more  complicated.  The 
imperfect  lip  prevents  the  child  from  grasping  the  nipple ;  and 
swallowing  is  rendered  difficult ,  since  this  function,  to  be  easily 
done,  requires  that  the  mouth  be  closed.  Where  the  breach  is 
great,  the  infant  breathes  through  its  mouth ;  and  the  air,  not 
warmed,  as  it  normally  is  by  passing  through  the  nose,  becomes 
the  causal  agent  of  catarrhal  and  pulmonary  trouble;  thus, 
between  hampered  nutrition  and  pulmonary  affection,  the  chances 
of  life  are  materially  lessened.  Hence  surgical  relief  of  such 
cases  is  early  and  urgently  sought  for  by  the  infant's  parents.  By 
the  mother  who  has  just  escaped  through  the  throes  of  labor,  no 
question  is  more  earnestly  asked  than  whether  her  child  is  per- 
fect in  form,  and  no  more  appalling  words  can  fall  on  her  ear 
than  the  answer  that  it  is  deformed.  Xo  persuasion  is  required 
to  induce  parents  in  such  emergency  to  commit  the  unfortunate 
one  to  the  surgeon's  hands;  and  the  first  C|uestion  to  determine 
is:  What  is  the  proper  period  to  operate  on  the  child?  and  this 
question  has  been  answered  differently  by  authorities  who  have 
written  on  hare-lip. 

■  In  a  review  of  this  matter  published  iu  1S42,  the  mass  of 
authority  favored  operating  in  the  early  months  of  infancy,  viz., 
about  the  end  of  the  third  month ;  this  was  the  time  preferred  by 
Dupuytren,  Houston  and  others;  Godefroy  operated  at  birth,  yet 
Dupuytren  opposed  operating  at  this  time,  since  he  thought  the 
parts  are  then  too  soft,  and  are  more  easily  cut  by  the  retaining 
pins,  than  they  are  at  a  later  period.  Dubois  the  accoucheur,  in 
1845,  in  a  communication  to  the  Academy  of  Medicine,  recom- 
mended earh^  operations  in  strong  and  healthy  infants. 

Roux  advocated  doing  the  operation  at  birth:  the  reasons  he 
offered  were  the  following:  "The  new-born  infant  is  patient, 
tractable,  and  without  knowledge  of  what  one  is  going  to  do,  or 
does  do,  on  him;  and  he  is  without  will  or  power  to  resist  or 
withdraw  himself  from  what  gives  him  pain  :  he  has  no  knowl- 
edge of  pain,  nor  does  he  fear  it ;  and  hence  he  is  not  agitated  ; 
nor  does  he  make  any  movements  which  will  interfere  with  the 
operation  and  its  results.  The  muscles  at  that  time,  including 
those  of  the  face,  have  but  little  power;  those  of  the  mouth 
have  no  force  beyond  the  function  of  suction  ;  hence  one  need  not 
fear  brisk  and  violent  movements  of  the  lips  and  cheeks,  nor 
efforts  of  retraction  which  can  cause  tearing  and  separation  of  the 


564  MOUTH  AND  ORAL  CAVITY. 

united  parts.  Besides,  the  tissues  which  are  operated  on  have 
great  vitaUty,  and  hence  great  })lasticity,  and  a  tendency  to  heal: 
and  this  tendency  is  greater  2)robably  than  at  any  other  })erio(l  of 
life."  These  opinions  of  Dubois  and  Roux,  for  a  time,  had  a  great 
following;  but  in  1S5G  a  number  of  unfortunate  operations  were 
reported,  and  tended  to  alter  o})inion  on  this  subject. 

Periat,  in  18.37,  in  a  thesis  sought  to  settle  the  matter  by  col- 
lecting a  scries  of  cases  wliich  had  been  operated  on  at  different 
ages,  and  weighing  the  results  in  the  scales  of  statistics.  The 
first  series  comprised  fifty  cases,  consisting  of  thirteen  of  simple 
form  and  thirty-seven  of  double  hare-lip  with  complications;  there 
were  three  deaths,  five  failures  and  forty-two  successes.  The 
operation  was  done  at  periods  varying  from  the  first  to  the 
thirtieth  day  after  birth.  In  a  second  series  consisting  of  forty- 
four  cases,  of  which  fourteen  were  simple  and  thirty  complicated 
hare-lip,  there  was  one  death,  four  failures  and  two  secondary 
reunions;  consequently  thirty-seven  successes.  These  infants 
were  operated  on  at  periods  varying  from  two  to  twenty-four 
months.  A  third  series  consisted  of  twenty-six  cases,  operated 
on  at  ages  varying  from  two  to  five  years;  of  these  one  died,  two 
were  failures,  and  two  were  secondary  unions.  Of  these  twenty- 
six  cases  seven  were  simple  and  nineteen  were  complicated.  In 
a  fourth  series  done  at  a  late  period,  comprising  forty-nine  cases, 
of  which  seventeen  were  simple  and  thirty-two  complicated,  there 
was  no  death,  and  all  the  operations  were  successful. 

The  operations  here  enumerated  amounted  in  all  to  one 
hundred  and  sixty-nine,  of  w^hich  one  hundred  and  forty-nine 
ended  successfully,  five  died,  ten  were  ftiilures  and  five  were  but 
partially  successful.  The  operations  were  done  by  leading  sur- 
geons of  France;  it  is  possible  that  these  figures  do  ]iot  represent 
the  whole  of  their  operations.  In  statistical  logic,  fallacies  often 
lurk  which  are  difficult  to  eliminate;  that  such  fallacy  does  here 
exist  is  evident  when  these  figures  are  compared  with  others 
which  have  been  reported.  In  reflexions  appended  to  a  report 
of  ninety-eight  operations  for  the  case  of  hare-lip  done  by  himself, 
Eigenbrodt,  in  1885,  alludes  ominously  to  the  mortality  which 
attends  the  operation,  Fritsch  found  that  it  was  fifty  per  cent 
in  Zurich,  and  Herrmann  reported  that  it  was  the  same  in 
Breslau.  And  wliere  hare-lip  is  double  and  complicated  witli 
palatal  cleft,  a  still  greater  number  die,  viz.,  of  sixty-eight  cases, 
sixt3'-five  per  cent  died.  Volkmann  takes  a  j^et  more  gloomy 
view  of  the   results  of  operation  for  the  cure  of  hare-lip  with 


LABIUM   LEPORINUM.  565 

palatal  complication ;  he  finds  that  such  cases,  if  they  do  not  die 
at  the  time  of  the  operation,  generally  do  so  within  a  year  after- 
wards. 

These  figures,  which  are  probably  correctly  reported,  differ  so 
greatly  from  those  of  Periat,  that  one  must  conclude  that  the 
figures  used  by  him  did  not  fully  represent  the  number  of  the 
unfortunate  cases  which  occurred.  The  writer,  who  has  had  an 
extensive  experience  in  the  operation  for  hare-lip,  thinks  that  the 
figures  of  recovery  of  Periat,  though  too  small,  more  nearly  repre- 
sent facts  as  observed  in  private  practice,  than  do  those  of  Eigen- 
brodt,  whose  figures  represent  fatality  in  dispensary  or  hospital 
practice.  That  so  great  a  fatality  as  fifty  per  cent  should  have 
attended  the  work  of  the  skilled  hand  of  the  j)ainstaking  German 
surgeon,  can  only  be  accounted  for  by  the  supposition  that  the 
cases  after  being  operated  on  passed  out  of  sight  of  the  operator 
into  the  hands  of  ignorant  jjarents,  who,  too  often,  do  not  find 
unalloyed  evil  in  the  death  of  such  child.  It  has  been  the 
writer's  observation  that  the  operation  for  hare-lip  is  very  rarely 
followed  by  death,  if  the  surgeon  carefully  watches  the  case.  And 
if  the  author  were  to  formulate  a  rule  which  should  be  religiously 
observed,  it  is  that  the  surgeon's  attention  should,  by  no  means, 
cease  with  the  OiDcrative  act,  but  that  he  should  carefully  watch 
his  patient  afterwards;  his  obligations  to  surgical  art  and  science 
demand  this;  and  his  duties  to  a  human  being,  wdiich  has 
intrusted  its  life  to  him,  with  a  solemn  and  impressive  emphasis 
command  this. 

The  question  is  usually  put  to  the  surgeon,  whether  he  can  restore 
the  cleft  lip  to  normal  form;  in  case  of  the  simple  uncomplicated 
cleft,  this  may  be  answered  affirmatively;  and,  likewise,  that  the 
danger  to  the  child's  lip  will  be  very  slight.  If  it  be  a  case  of 
double  hare-lip  complicated  with  other  deformity,  the  result  will 
be  less  perfect,  and  there  will  be  some  risk  of  the  child  dying 
from  the  operation.  The  defects,  which  may  be  left  after  the 
operations,  have  been  studied  by  Neudorfer  in  1858,  and  are 
classified  by  him  as  follow^s :  (1)  The  edge  of  the  lip  may  remain 
lower  on  one  side  than  on  the  other.  (2)  On  the  outside,  though 
union  has  been  obtained,  a  vertical  furrow  may  remain.  (3)  A 
V-sha];)ed  defect  may  remain  at  the  site  of  union,  and  this  defect 
constitutes  ninety  per  cent  of  all  the  defects  resulting  from  hare- 
lip operations. 

In  the  writer's  opinion,  the  defects  mentioned  may  be  referred 
rather  to  the  operator  than  the  operation ;  since  by  careful  work 


566  MOUTH  AND  ORAL  CAVITY. 

and  dexterity  acquired  through  experience,  the  defects  mentioned 
may  be  avoided,  or  greatly  lessened.  From  the  author's  observa- 
tion, the  most  glaring  and  striking  defect  is  that  which  remains 
after  operations  on  hare-lip,  in  which  the  cleft  extends  into  one 
or  both  nostrils,  and  the  wings  of  the  nose  rest  obliquely  on  the 
face.  This  flaring  nostril  is  oftener  on  tlie  left  side;  and  besides 
the  obliquity,  the  two  sides  of  tlie  nose  are  not  syninietrical.  To 
correct  such  asymmetry  and  obliquity,  and  to  erase  the  V  from 
the  lower  margin,  are  problems  susceptible  of  fairly  satisfactory 
solution.  The  guiding  rule  or  general  principle  involved  in 
the  operation  is  to  remove  the  margins  of  the  cleft,  and  then  unite 
the  opposite  raw  surfaces  so  that  similar  textures  will  be  con- 
joined; special  pains  being  taken  that  the  outer  surface  be  levels 
and  hence  free  from  irregularities. 

Operation. — As  instruments  needed  in  the  operation  are  the 
following:  scalpel,  scissors,  htemostatic  clasps  or  forceps,  a  flat 
piece  of  wood  to  be  placed  under  the  lip  as  it  is  incised,  materials 
for  suture  and  adhesive  stri2:is  to  immobilize  the  wounded  parts. 

In  the  early  history  of  the  operation,  closure  of  the  wounded 
parts  was  effected  by  means  of  adhesive  plaster  and  a  variety  of 
cumbersome  appliances;  these  have  properly  been  consigned  to 
disuse,  and  the  work  of  union  is  now  universally  accomplished 
by  suture  of  either  the  knotted  or  twisted  species.  -As  to  the 
choice  between  these,  authority  is  about  equally  divided.  The 
simple  knotted  suture  is  advised  by  the  following  surgeons: 
Mirault,  Guersant,  Woakes,  Boeckel,  Giraldes  and  Hamilton. 
The  twisted  suture,  or  that  done  by  means  of  pins  and  thread,  is 
advised  by  Thierry,  Ancelon,  Langenbeck,  Bruns  and  Tricot. 
Thierry,  to  avoid  the  cutting  of  the  skin  which  often  occurs  when 
the  twisted  suture  is  used,  closes  the  parts  by  means  of  a  small 
nut  which  is  screwed  on  the  transfixing  pin;  his  plan  is  not  fol- 
lowed. To  avoid  this  cutting,  Tricot  used  an  elastic  thread 
which  he  pa.ssed  around  the  inserted  ])ins. 

A  reserve  or  tension-relieving  suture  was  used  by  Woakes,, 
Boeckel  and  others.  And  this  suture  placed  at  some  distance 
from  the  border  of  the  wound,  was  used  by  some  surgeons  along 
with  thin  plates  of  metal,  hard  rubber,  bone  or  ivory;  the  sutures 
passed  through  apertures  in  these  plates,  so  that,  when  tied  or 
closed,  the  sutures  pressed  on  the  plates,  and  not  on  the  included 
labial  structures.  Such  protective  supports  were  used  by  Denon- 
viliers  in  1856;  he  u.sed  two,  one  on  the  in.side  and  one  on  the 
outside,  made  of  India  rubber.     After  the  threads  traverse  these 


LABIUM    LEPOEIXUM.  567 

plates,  they  are  to  be  tied  over  a  roller;  and  after  twenty-four 
hours,  Denonviliers  finds  that  union  has  taken  place. 

The  ingenuity  of  surgery  has  been  exerted  to  avoid  the 
V-shaped  defect  in  the  labial  boraer  at  the  site  of  closure.  The 
ways  devised  to  accomplish  this  may  be  grouped  in  four  classes: 
(1)  By  introducing  the  pins  in  a  direction  tending  to  lengthen 
the  vertical  span  of  the  lips.  (2)  Marginal  suture.  (3)  By  a  spe- 
cial shape  of  the  vertical  wounds.  (4)  Flaps  double  or  single  cut 
from  the  sides  or  side  of  the  cleft;  or  a  loop -form  incision  ma}^ 
be  used. 

1.  To  depress  the  site  of  closure,  the  transfixing  pin  has  been 
caused  to  enter  straighi;,  and  then  to  have  its  point  rise,  and  then 
afterwards  to  descend  again;  the  effect  intended  is  to  force  the 
structure  downward,  and  the  action  is  similar  to  that  of  the 
acupressure  needle,  which  is  so  passed  as  to  compress  the  subja- 
cent ve.ssel.     This  plan  is  no  longer  used. 

2.  An  attempt  to  depress  the  border  has  been  tried  by  means 
of  a  horizontal  suture  beneath  the  wound;  this  plan  has  acted  as 
ineffectually  as  the  preceding  one. 

3.  Better  results  have  been  attained  by  giving  the  vertical 
wound  such  a  form  that  the  border  or  borders  become  elongated 
when  juxtaposed.  For  example,  if  one  side  of  the  cleft  be 
longer  than  the  other,  Dieffenbach  trimmed  the  longer  one  by  a 
straight  incision,  while  the  shorter  side  was  so  trimmed  as  to 
present  a  concave  outline.  The  result  would  be,  when  the  wound 
was  closed,  to  straighten,  and  hence  to  lengthen  the  concavely 
wounded  side.  Tricot,  in  his  dissertation  on  hare-lip,  advises  thi.? 
mode  of  avoiding  defect.  And  in  case  both  borders  of  the  cleft 
be  short,  then  each  border  may  be  trimmed  with  concavities  fac- 
ing each  other,  as  shown  in  Figure  77;  the  effect  of  this  would 


Figure  77.    Showing  Graefe's  plan  FicrRE  78.     Showing  Giaefe's  plan 

of   elongating   the   boideis  b}'   trim-      as  modified  by  Bruns.    (From  Weber.) 

mills  them  ooucmvpIv. 


568  MOUTH  AND  ORAL  CAVITY. 

be  to  lengthen  each  border  when  the  sides  are  exposed;  thus 
Graefe  adv'ised  the  work  to  be  done,  in  order  to  shun  the  V-defect. 
In  Figure  78  there  is  exhibited  a  nioditication  of  Grajfe's  plan  as 
practiced  by  Bruns. 

4.  In  plastic  work  done  to  remedy  defects,  it  should  be  an 
inviolate  rule  to  sacriiice  no  structural  material  if  this  can  be 
utilized;  and  nowhere  is  this  more  imperatively  necessary  than 
in  the  repair  and  reconstruction  of  labial  and  palatal  cleft. 
This  rule  applies  preeminently  in  the  solution  of  the  problem  to 
avoid  the  Y-defect.  For  it  is  possible,  through  ingeniously 
devised  incisions,  to  retain  the  marginal  structure  of  the  cleft, 
and  to  make  it  do  the  service  of  closing  up  the  gap  wdiich 
otherwi.se  would  remain  on  the  edge  of  the  lip.  In  case  the 
cleft  be  single  and  does  not  extend  up  into  the  nostril,  Sedillot, 
Nelaton  and  Cl^mot  make  an  incision  which  is  so  directed  as  to 
circumscribe  the  summit  and  sides  of  the  cleft  in  such  a  man- 
ner that  the  uplifted  edge  is  attached  below  on  each  side,  and 
resembles  a  loop  or  swinging  bridge.  "When  this  is  closed, 
instead  of  an  underlying  A^-gap,  there  will  remain  a  slight  prom- 
inence, as  shown  in  Figure  80. 


\ 

'V"' ' 


Figure  79.    Showing  form  of  flap  Figure  80.     Result  after  partial 

shaped  like  a  swinging  bridge,  prac-        closure, 
ticed  by  Sedillot. 

The  same  closure  may  be  done  b}'  means  of  a  flap  formed  on 
each  side,  and  which  hangs  at  the  base  of  the  breach,  as  shown  in 
Figure  81.  A  correct  idea  of  this  is  obtained  by  conceiving  a 
loop  formed  as  above  described,  and  then  cutting  out  the 
middle  third  of  the  loop.  This  method,  or  a  modification  of 
it,  was  first  suggested  and  practiced  by  Mirault  of  France; 
and  soon  afterwards  employed   by  Henri,  Malgaigne,  Langen- 


LABIUM    LEPORIXUM. 


569 


FiGUKE  81.  yiiowiug  lateral  pend- 
ent flaps  which  were  employed  by 
Mirault,  Henri  and  Malgaigne. 


Figure  82.  Showing  result  when 
flaps  have  been  united,  and  surplus 
material  has  been  excised. 


beck  and  others.  The  author  early  in  his  professional  career 
practiced  a  modification  of  this  method,  and  believed  at  the 
time  that  he  had  originated  it;  he  learned  later  that  his  work 
had,  like  that  of  many  another  inventor,  been  antedated  by  some- 
one else;  for,  as  history  shows,  many  aloud-heralded  invention  or 
discovery  is  but  the " repetition  of  something  which  has  gone 
before.  A  wider  range  of  knowledge  would  have  mufHed  the 
herald's  voice.  Such  prophylactic  knowledge  abounds  in  the 
writings  of  Hippocrates. 


FiGVEE   83.       Showing 
Mirault's  method, 
ing  flap  on  the  left  side 


Figure  84.  Ee- 
sult  of  work  done  as 
shown  in  Figure  83 
when  closed. 


Figure  x.  Showing  the  in- 
cisions to  be  made  for  closure  of 
double  hare-lip. 

Mirault,  in  his  method  as  shown  in  Figure  83,  formed  lateral 
flaps  which  were  attached  to  the  base  of  the  cleft.  The  mucous 
membrane  is  trimmed  off  from  one  of  these  flaps,  and  retained 
on  the  other.  The  breach  is  next  closed  b}'-  sutures,  and  the  flaps 
so  disposed  that  the  one  which  retains  its  mucous  membrane  will 
lie  outermost.  The  pendent  flaps  being  sutured  in  horizontal 
position  comoletelv  close  the  cleft  below.  Malgaigne  and  Henri 
37 


570  MOUTH    AND    OKAL    TAVITY. 

formed  lateral  hanging  flaps,  as  shown  in  Figure  81 ;  and  these 
flaps  were  united  by  their  raw  surfaces,  and  the  surplus  tissue 
afterwards  excised. 

Wliichever  of  these  modifications  is  chosen,  the  operator 
will  surely  have  enough  material  to  fill  the  gap  on  the  border; 
in  fact,  there  is  more  material  than  is  needed,  so  that  afterwards 
a  part  must  bo  trimmed  oft\  And  should  the  surgeon  desire  to 
change  his  phm,  when  lie  has  formed  these  flaps,  he  can  easily 
modify  it  so  as  to  conform  to  the-^lan  next  to  be  described,  viz., 
that  of  the  single  flap. 

The  method  of  doing  the  work  by  means  of  a  single  flap  to 
avoid  the  V-gap  is  sometimes  erroneously  referred  to  Mirault; 
still,  to  him  surgery  is  indebted  for  the  idea  of  swinging  flaps, 
dependent  below  with  lateral  attachment,  for  closure  of  the  labial 
cleft,  and  his  idea  suggested  the  modifications  employed  by  sub- 
sequent operators.  Langenbeck  used  the  single  flap  in  some 
cases;  yet  his  plan  is  defective  in  this  respect  that  he  formed  this 
flap  from  the  right  side  in  the  case  of  cleft  on  the  left  side.  For 
over  a  quarter  of  a  century  the  writer  has  used  the  single  flap  in 
closure  of  the  simpler  as  well  as  of  the  complicated  forms  of  hare- 
lip. To  do  this  in  the  best  manner,  if  it  be  a  cleft  of  the  left  side, 
first  remove  tlie  border  on  the  riglit  side  by  a  vertical  incision, 
and,  when  this  cut  is  near  the  lower  border,  let  the  knife  continue 
its  work  for  at  least  two  lines  horizontally  towards  the  right,  and 
finish  by  cutting  tlie  flap  off.  Thus  a  raw  surface  in  L-sha4)e  is 
formed.  And  the  horizontal  part  of  the  L  should  not  terminate 
acutely,  but  should  have  a  blunt  ending.  In  making  this  incisior 
the  section  must  be  as  perpendicular  as  possible  to  the  surface  of 
the  lip,  and  at  its  end  below,  it  leaves  a  rectangular  notch.  Next, 
from  the  left  side,  let  a  flap  be  formed  which  will  hang  from  the 
left  border  of  the  cleft  by  a  pedicle  which  is  a  line,  at  least,  in 
thickness.  This  flap  should  commence  at  the  apex  of  the  cleft, 
and  be  a  continuation  of  the  right  incision,  and,  like  the  right 
one,  the  left  section  must  be  perpendicular  to  the  labial  surface. 
The  hanging  flap  should  now  be  brought  across  the  base  of  tlie 
cleft,  and  the  raw  sides  of  the  same  apposed;  then  it  will  com- 
monly occur  that  the  flap  which  has  been  formed  will  be  too 
long,  and,  if  so,  a  part  of  the  free  end  may  be  excised,  but  in  this 
excision  care  must  be  used  not  to  shorten  too  much;  also  the  flap 
must  end  bluntly,  so  that  it  will  fit  and  fill  the  notch  on  the 
border. 

After  these  preliminary  statements,  the  writer  will  proceed  to 


LABIUM    LEPORINUM.  571 

describe  the  proeedures  to  be  pursued  in  the  closure  of  hare-lip  of 
different  grades,  beginning  with  the  most  simple  form,  in  which 
tlie  cleft  does  not  reach  to  the  nostril.  The  operator  should  first 
examine  whether  the  sides  of  the  cleft  are  adherent  to  the  upper 
jaw,  and,  in  most  cases,  such  adherence  will  be  found  only  on 
one  side.  The  child  being  anaesthetized  for  the  operation,  such 
adhesion  must  be  severed,  and  this  may  be  done  with  scissors, 
knife,  or  the  blade  of  a  thermal  cautery.  When  the  child  is 
feeble,  or  where"  extensive  division  must  be  made,  the  thermal 
blade  is  preferable,  since  in  this  way  blood  is  spared.  Sometimes 
no  abnormal  adhesion  exists,  and  still  the  operation  will  be 
rendered  much  easier  if  the  upper  lip  adjacent  to  the  cleft  be 
freely  separated  from  the  upper  jaw.  If  this  be  done  with  the 
scalpel,  as  is  commonly  the  case,  less  blood  will  be  lost  if  the 
labio-alveolar  cul-de-sac  of  mucous  membrane  be  divided  close  to 
the  jaw,  and  then  the  detachment  be  continued  sub-periosteally, 
with  a  blunt  dissector. 

The  right  side  of  the  cleft  should  first  be  removed  in  the 
manner  above  described,  the  incision  beginning  above  and  on 
the  left  side  of  the  summit  of  the  cleft.  Care  must  be  taken  that 
this  incision  fully  include  the  border  at  the  vertex,  and  that  no 
dermal  fragment  be  left  which  would  interfere  with  union.  And 
this  will  best  be  done  if  the  flap  removed  from  the  child's  right 
side  pass  over  the  vertex  of  the  cleft  and  extend  the  distance  of 
two  lines  on  the  child's  left  side.  This  cutting  is  best  done  with 
a  scalpel  of  short  blade  and  sharp  point,  and  tlie  cutting  should 
be  done  on  a  surface  of  wood  which  may  be  formed  from  a 
shingle,  and  this  wood  should  be  three  inches  long  and  two 
inches  broad.  Tlie  work  could  not  be  done  so  well  with  scissors, 
since  the  initial  part  of  each  section  should  commence  at  the 
vertex  by  transfixion.  Besides,  incision  with  scissors  tends  to 
leave  inversion  of  the  inner  and  outer  surfaces  of  the  divided 
structure.  While  this  cutting  is  being  done,  bleeding  is  to  be 
controlled  by  compression  made  at  the  labial  angles  by  forceps  or 
the  fingers  of  an  assistant. 

The  wounded  parts,  as  thus  prepared,  are  next  to  be  closed  by 
suture,  and  this  is  best  done  by  the  interrupted  species  in  which 
no  transfixing  pins  are  used.  The  best  material  for  suture  is 
fine  copper  wire  which  has  been  well  gilded,  that  is,  covered  with 
gold.  Such  copper  wire  is  stronger  than  that  of  silver  of  the 
same  thickness;  it  is  so  pliant  that  the  ends  can  easily  be  united 
by  twisting  or  tying.      Thread  might  be  used,  yet  it  irritates 


572  ^MOUTH    AND    ORAf,    CAVITY. 

more  than  metallic  suture.  lu  most  of  the  work  clone,  this  tune 
wire  should  be  doubled,  and  if  much  tension  is  to  be  overcome,  it 
may  be  used  triple  or  even  cjuadruple. 

For  the  sutural  closure  of  a  simple  hare-lip,  the  author  uses 
four  sutures;  two  of  these  are  deep,  in  which  the  double  wire  is 
used,  and  in  two,  single  wire  is  used.  The  first  deep  suture 
should  be  carried  through  the  entire  thickness  of  the  lip,  at  the 
lower  part  of  the  cleft,  after  the  sides  have  been  thoughtfully  coap- 
tated.  The  wire  is  carried  through  by  means 'of  a  moderately 
curved  needle,  which  is  so  long  that,  when  it  has  passed  through 
the  two  sides,  its  head  will  remain  projecting  beyond  the  entrance 
point,  and  the  point  of  the  needle  will  project  a  half  inch  at  least 
after  its  emergence  on  the  right  side  of  the  cleft.  Such  a  needle 
is  much  more  easily  used  than  a  shorter  one.  Since  the  coronary 
arterv  lies  near  the  mucous  membrane,  the  needle  nnist  pierce 
the  entire  thickness  of  the  lip,  so  that  the  wire,  when  closed,  will 
circumscribe  the  vessel  and  prevent  bleeding,  which  must  occui- 
if  the  wound  be  left  open  on  the  side  of  the  mucous  membrane. 
Neglect  of  this  has  permitted  the  blood  to  flow  unseen  after  the 
operation  has  been  completed;  and  to  this  cause  may  be  referred 
much  of  the  mortality  after  this  operation.  The  second  deep 
suture,  likewise  transfixing  the  entire  thickness,  is  next  to  be 
passed  below  the  vertex  of  the  cleft.  These  deep  sutures  should 
enter  and  emerge  at  a  distance  of  not  less  than  a  quarter  of  an 
inch  from  the  edge  of  the  cleft.  In  case  the  labial  material  is 
scant  and  there  is  much  tension,  it  is  well  to  let  at  least  one  of  the 
deep  sutures  enter  and  emerge  a  half  inch  from  the  edge  of  the 
cleft. 

A  third  suture  is  next  to  be  introduced  between  the  deep  ones 
and  much  more  superficially;  this  suture,  consisting  of  a  single 
wire,  is  to  reduce  the  included  surface  to  a  level,  and  to  maintain 
it  so  during  the  subseciuent  swelling  of  the  parts.  The  fourth 
suture,  likewi.se  of  single  wire,  is  to  be  introduced  through  the  mid- 
dle of  the  base  of  the  swinging  flap  and  then  to  pass  through  the 
lower  part  of  the  right  side  of  the  cleft,  and  to  emerge  beyond  the 
anoular  notch  in  which  the  flap's  end  is  to  fit.  If  this  suture  be 
properly  passed,  it  will  hold  tlie  entirety  of  this  flap  in  its 
destined  horizontal  site,  and  the  flap  will  completely  fill  the  gap 
which  was  wont  to  remain  after  the  former  methods  of  closure. 
Should  the  fla})  be  found  to  be  too  long,  and  by  its  pouting 
downwards  form  too  large  a  tuberculum,  then  enough  should  be 
cut  from  the  end  to  leave  material  which  will  form  a  normal 


LABIUM    LEPORINU-M.  573 

eminence  at  the  middle  of  the  lip.  After  the  introduction  of  the 
four  sutures,  sliould  the  wound  gap  or  present  an  uneven  surface 
at  some  point,  tlien  another  fine  suture  should  be  used. 

The  "writer  closes  the  wire,  not  by  tying,  but  by  twisting  the 
ends  together;  and  his  custom  is  to  cut  short  one  end  and  leave 
the  other  an  inch  or  more  in  length.  The  wire  should  be  closed 
at  one  side  of  the  wound,  and  never  over  it.  It  should  not  be 
closed  too  tightly :  merely  enough  to  unite  the  sides  of  the  wound; 
more  pressure  will  pinch  and  pain  the  child,  and  cause  the  wire 
to  cut.  The  long  ends  of  the  wire  of  the  three  upper  sutures 
should  be  laid  horizontally,  while  the  end  of  the  one  which  fixes 
the  flap  should  be  turned  obliquely  upwards.  After  the  sutures 
are  in  place,  the  line  of  the  wound  should  be  coated  with  the 
compound  tincture  of  benzoin,  whicli  forms  a  varnish-like  cover- 
ing which  is  impervious  to  the  fluids  of  the  mouth.  The  ends 
of  the  wires  are  now  to  be  covered  with  strips  of  adhesive  plaster, 
which,  commencing  below  the  lobule  of  the  ear  on  one  side,  are 
carried  across  the  wound  upwards  on  the  cheek,  to  end  above  the 
other  ear.  These  strips  may  be  three  or  four  in  number;  and 
when  properl}'-  placed,  they  alternatelv  cross  each  other  on  the 
wound.  And,  lastly,  to  maintain  these  crucially  disposed  strips, 
one  or  more  strips  must  be  placed  vertically,  forming  a  loop 
under  the  chin.  In  placing  the  first  series  of  retaining  strips, 
the  ends  of  the  wires  must  be  covered  completely;  and  especiallv 
the  one  that  pierces  the  flap. 

The  adhesive  strips  have  a  tendency  to  slip  down  over  the 
edge  of  the  lip;  and  to  avoid  this,  they  should  be  narrow  and 
placed  well  up  towards  the  nose.  These  retaining  and  immo- 
bilizing strips  should  consist  of  rubber  plaster,  which  is  insoluble 
in,  and  impermeable  to,  saliva,  milk  or  other  fluid  which  may 
come  in  contact  with  it.  These  strips  applied  in  the  manner 
described,  draw  the  adjacent  parts  towards  the  wound,  and  hence 
they  diminish  the  tension  of  the  sutures. 

After  forty-eight  hours  the  upper  one  of  the  deep  sutures 
should  be  removed;  and  this  is  done  by  dividing  the  crucial 
strips  on  one  side,  so  that  the  portion  of  them  covering  the 
sutures  may  be  uplifted,  and  then  the  long  end  of  the  upper 
suture  is  to  be  seized  and  drawn  on  so  that  the  wire  can  be  cut 
on  the  opposite  side,  close  to  the  skin.  The  wire  should  be  so 
drawn  on  that,  when  it  is  severed,  the  cut  end  will  sink  back  into 
its  orifice;  now  by  pulling  on  the  long  free  end,  and  at  the  same 
time  supporting  the  parts  on  each    side,  the    suture    is  easily 


574  MOUTH  AXD  ORAL  CAVITY. 

drawn  out.  By  lluis  dividing  the  suture  through  a  portion 
wliich  was  buried,  the  end  which  is  drawn  on  will  have  no 
dried  excreta  on  it,  and  will  easilv  forsake  its  canal.  As  soon 
as  the  suture  is  removed,  its  track  is  re-covered  "vvith  the  ad- 
liesive  strii)s  sui)])orted  by  a  new  strip  on  each  side.  At  the 
end  of  three  days,  if  union  seems  complete  and  firm,  the  lower 
deep  suture  may  be  removed;  and  also  the  intermediate  suture; 
the  work  being  done  as  in  the  removal  of  the  preceding  suture. 
There  now  remains  but  one  suture,  viz.,  the  marginal  one,  wdiich 
may  be  removed  on  the  fifth  or  sixth  day,  according  as  the 
union  seems  solid.  The  supporting  adhesive  strips  should 
remain  in  place  for  at  least  one  week  after  the  operation  has  been 
done. 

Instead  of  the  deep  suture  of  wire  here  described,  one  may 
use  the  twisted  suture,  in  wddch  the  so-called  hare-lip  pin  is  used. 
Tlie  author  has  frequently  employed  this  plan,  and  obtained  sat- 
isfactory results.  It  is  used  as  follows:  The  cleft  having  been 
trimmed  and  a  swinging  flap  prepared  as  described,  two  pins  are 
to  be  introduced,  occupying  the  sites  directed  for  the  deep  wire 
sutures.  These  pins  should  pass  quite  through  the  thickness  of 
the  lip,  so  as  to  prevent  hemorrhage.  The  next  step  is  to  twist 
the  silk  thread  around  the  inserted  pins.  The  points  of  the  pins 
are  finally  to  be  cut  off  by  means  of  a  special  instrument  known 
among  mechanics  as  pliers;  such  an  instrument  cuts  without 
displacing  the  pin.  And  to  prevent  the  heads  and  points  of  the 
pins  from  cutting  the  surface  beneath  them,  short  strips  of 
adhesive  plaster  should  be  inserted  between  them  and  the  skin. 
The  next  step  is  to  fix  the  swinging  flap  in  its  place  by  means  of 
a  single  wire  suture.  The  long  end  of  this  suture  is  to  be  turned 
upw^ards,  and  the  whole  to  be  covered  by  the  rubber  adhesive 
strips  before  described.  Should  there  be  but  little  tension  of  the 
parts,  short  strips  placed  horizontally  will  sufficiently  immobil- 
ize them. 

In  regard  to  the  time  when  the  pins  should  be  removed, 
opinion  and  practice  vary;  Langenbeck,  for  example,  removed 
them  on  the  second  day,  but  to  prevent  the  closed  parts  from 
rupturing,  the  thread  wdiich  surrounded  the  pins  was  allowed  to 
remain  in  place,  having  previously  been  fixed  there  by  a  coat  of 
collodion,  applied  at  the  time  when  the  operation  was  done. 
Other  operators,  again,  remove  one  in  forty-eight  hours,  and  the 
other  at  the  end  of  the  third  day;  or  even  a  day  or  two  later,  in 
cases  in  which  separation  of  the  Avound  is  feared.     And  here,  as 


DOUBLE    HARE-LIP.  575 

in  the  case  of  the  knotted  suture,  the  unhealed  wound  should  be 
supported  by  protective  strips  of  adhesive  plaster.  The  act  of 
removing  the  pins  requires  care;  the  sides  adjacent  should  be 
supjDorted  by  the  hands  of  an  assistant,  and  he  should  be 
instructed  to  support  the  parts  gently,  and  not  to  press  Yiolentl}^ 
lest  the  tenderly  united  wound  be  caused  to  open.  And  similar 
precaution  should  be  used  in  the  removal  of  the  interrupted  or 
knotted  suture.  And  should  it  happen  that  the  wound  is  opened 
in  the  extraction  of  the  first  pin  or  suture,  then  the  remaining 
one  should  be  allowed  to  continue  in  place  two  or  three  days 
longer,  and  the  reopened  wound  closed  by  adhesive  strips;  thus 
proceeding,  the  wound  will  re-heal  in  a  da}^  or  two. 

Operation  on  Uncomplicated  Double  Hare-lip. — The  operative 
work  of  closing  the  double  hare-lip  of  simple  form  is  quite  sim- 
ilar to  that,  already  described,  which  is  done  for  the  closure  of 
simple  labial  cleft;  yet  the  operation  is  a  more  extended  one,  and 
is  more  difficult. 

In  case  the  cleft  is  a  broad  one,  the  work  should  begin  with 
the  formation  of  a  flap  on  each  side  wdiicli  will  depend  from  the 
border  below,  similar  to  the  flaps  which  are  made  in  Malgaigne's 
operation  before  mentioned.*  Next,  the  intervening  V-shaped 
part  of  the  cleft  is  to  be  pared;  and  then  the  raw  surfaces  are  to 
be  closed  by  two  wire  sutures  which  include  the  thickness  of  the 
lip;  or,  instead  of  the  interrupted  suture,  pins  ma}^  be  used  for 
closure.  The  closure  of  the  lateral  wounded  border  with  the 
median  angular  part  is  seldom  satisfactorily  done;  the  angular 
part  usually  remains  higher,  and  sits  like  a  promontory  between 
the  sides  which  are  united  to  it.  And  where  this  has  threatened 
to  remain  a  permanent  deformit}',  and  disfigure  the  lip,  the 
writer  in  operating  has  preferred  to  wdioUy  sacrifice  the  angular 
part  rather  than  to  attempt  to  adjust  the  discordant  promontory 
to  its  surroundings.  But  if  it  be  thought  better  to  retain  the 
median  part,  then  in  closure  the  suture  should  pass  through  the 
apex  of  the  Y-portion,  after  the  latter  has  been  prepared  and 
drawn  well  downwards.  If  one  partially  separates  this  angular 
median  part  from  the  upper  jaw,  and  finds  that  it  is  so  thick  as 
to  rise  above  the  lateral  parts,  it  may  be  pared  slightly  under- 
neath, so  as  to  be  on  a  level  with  the  contiguous  parts.  The 
two  hanging  flaps,  which  have  been  formed  from  the  sides  of  the 
breach,  are  next  to  be  united  by  their  raw  surfaces,  and  surplus 
material  may  then  be  cut  from  the  end  of  these  united  flaps,  so 
that    enough    material  will    remain   to  fill  the    A"-shaped  gap 

*Seen  in  Fig.  x  on  page  569. 


576  MOUTH    AXD    ORAL    CAVITY. 

which  otherwise  would  remain.  In  this  closure,  the  author  uses 
and  recommends  the  metallic  suture  before  described.  Though 
pins  might  be  employed,  the  former  plan  has  been  found  to  act 
more  satisfactorily.  In  case  of  much  tension,  the  wire  cuts  less, 
and  can  be  allowed  to  remain  in  place  longer  than  pins.  The 
parts  should  be  supported  b}^  adhesive  strips,  and  the  sutures 
should  be  extracted,  successively,  on  the  third,  fourth  and  fifth 
days;  but  the  adhesive  strips  should  remain  a  few  days  longer. 

The  double  hare-lip  may  be  complicated  with  fissure  extend- 
ing through  the  alveolar  process  and  the  palatal  vault  of  the 
roof  of  the  mouth ;  and  such  alveolar  and  i)alatal  fissure  may  Ije 
single,  or  it  may  be  bilateral. 

As  previously  explained,  the  osseous  complication  here  men- 
tioned arises  from  defective  development  of  the  primitive  frontal 
and  maxillary  processes  of  the  embryo;  and  the  part  which  emi- 
nently figures  in  tlie  present  deformity  is  the  median  portion  into 
which  tlie  frontal  plates  are  transformed.  The  anterior  and 
inferior  end  of  this  develops  into  the  bone,  variou.sly  named 
the  incisive,  intermaxillary  or  premaxillary  bone;  and  in  tiie 
form  of  hare  lip  under  consideration  the  premaxillary  bone 
may  present  every  grade  of  growth  between  entire  absence  and 
almost  completed  form.  It  may  stand  almost  in  row  with  the 
broken  alveolar  arch  on  each  side;  or,  it  may  be  protruded  for- 
wards to  such  an  extent  that,  instead  of  .standing  vertical,  it  lies 
horizontal.  Also,  the  median  V-shajDed  fragment  of  the  lip  may 
be  of  con-siderable  size,  or  reduced  to  a  mere  vestige;  and  in  these 
particulars  it  resembles  the  premaxillary  bone  on  which  it  rests. 
The  adjacent  interrupted  alveolar  arch  often  presents  irregular- 
ities in  this  respect,  that  one  portion  of  it  stands  higher  than  the 
other;  and  something  analogous  to  this  sometimes  appears  in 
uncomplicated  double  hare-lip,  and  even  in  simple  hare-lip;  for 
frequently  there  appear  traces  of  retailed  closure  of  the  bones; 
and  one  side,  oftener  the  right  one,  is  protruded  beyond  the  other, 
so  as  to  render  the  alveolar  arch  irregular. 

Besides  the  extraordinary  deformity  with  which  complicated 
double  hare-lip  stamps  the  child,  the  latter  is  menaced  by  a  peril 
5^et  more  grave  in  the  interference  with  its  nutrition;  the  function 
of  suction  and  swallowing  becomes  difficult,  and  sometimes 
impossible  in  such  an  infant;  and  hence  an  operation  here  has  a 
double  object,  viz.,  to  restore  normal  form  and  to  aid  alimentation. 
The  work  to  be  done  is  a  severe  attack  on  the  infant's  vital 
resources;  and  the  question  has  been  much  disciLssed  at  what 


DOUBLE    HARE-LIP.  577 

time  should  the  operation  be  done.  The  mass  of  authority 
opposes  early  interference,  and  favors  delay,  until  the  child  has 
acquired  greater  strength,  and  has  greater  powers  of  resistance; 
and  this  time  is  fixed  at  from  three  to  six  months,  by  some;  others 
would  postpone  operating  until  the  child  is  four  or  five  years  old. 
The  majority  of  operators  do  the  work  of  entire  closure  at  one 
time;  others  claim  that  the  danger -to  life  is  lessened  if  half  of 
the  double  cleft  be  closed  at  one  time,  and  that  closure  be  completed 
at  a  later  time. 

The  author's  experience  justifies  him  in  advising  an  early 
operation;  for  the  new-born  appears  commonly  in  the  threshold 
of  existence  with  an  ample  supply  of  reserve  force  to  meet  the 
new  conditions  of  life  for  the  first  few  days;  and  as  a  consequence 
the  lungs  and  the  alimentary  canal,  which  must  hereafter  replace 
the  placenta,  commence  their  functions  leisurely.  Through  the 
unclosed  intercommunication  between  the  right  and  left  hearts, 
venous  blood,  for  a  time,  reaches  the  arteries,  and,  as  a  result, 
general  sensation  is  lessened  and  there  is  a  tolerance  of  trauma- 
tism in  any  form.  Also,  the  exposure  to  cold  air  through  the 
labial  breach,  if  closure  be  deferred,  may  induce  bronchial  and 
j)ulmonary  affection.  Such  are  reasons  which  plead  strongly  for 
an  operation  soon  after  birth,  and  have  induced  the  writer 
occasionally  to  operate  during  the  first  day  of  the  child's  life. 

The  child's  life  is  imperiled  by  the  large  quantity  of  blood 
which  is  usually  lost  at  the  time  of  the  operation;  also,  by  bleed- 
ing which  may  continue  after  the  work  is  done;  and  another 
danger  is  the  interference  with  respiration,  which  arises  from  the 
closure  of  the  nostrils,  which  is  often  temporarily  done  by  the 
operation;  and  such  interference  arises  also  through  the  closure 
of  the  child's  mouth  which  occurs  during  the  inspiratory  act. 
The  o^jeration  greatly  lessens  the  oral  opening,  so  that  when  the 
child  draws  in  its  breath  the  lips  fall  together,  valve-like,  and 
entirely  close  the  opening.  The  hsemorrhage  arises  from  the 
extensive  surface  which  is  wounded;  also  from  the  work  which  is 
done  in  the  disposal  of  the  premaxillary  bone.  The  writer  has 
found  that  some  blood  can  be  saved  by  using  the  thermal  cauter}^ 
to  detach  the  sides  and  summit  of  the  cleft  from  the  upper  jaw. 
And  other  hgemostatic  precautions  will  be  mentioned  when  the 
treatment  of  the  premaxillary  bone  is  considered.  The  breath- 
ing must  be  watched  by  a  nurse  who  will  vigilantly  discharge 
the  task  of  drawing  down  the  chin  or  lower  lip  whenever  the 
mouth  is  closed.     If  this  be  neglected  the  automatic  movements 


578  MOLTII    AND    ORAL    CAVITY. 

of  inspiration  and  expiration  will  be  repeated  witliont  the  admis- 
sion of  air  nntil  the  infant  becomes  e^'anosed  tlirougli  want  of 
oxygen. 

In  liare-lip  with  premaxillary  complication,  the  best  mode  of 
disposing  of  the  premaxillary  bone  is  a  question  which  has 
greatly  occupied  the  attention  of  surgeons ;  and  as  it  is  the  first 
act  in  the  operative  work,  it  will  liere  be  considered. 

In  the  early  or  developing  period  of  the  operation  on  tliis 
complicated  form  of  hare-lip,  the  older  surgeons  summarily  dis- 
posed of  the  difficulty  by  excising  the  premaxillary  bone,  and 
then  closed  the  labial  breach  in  the  same  way  as  double  hare-lip 
without  complication.  And  even  in  later  periods  this  practice 
was  pursued.  Volkmann,  for  example,  was  accustomed  to  sacri- 
fice the  bone.  Yet  this  plan  is  obnoxious  to  the  grave  charge 
that  it  lessens  tlie  arc  of  the  upper  jaw,  and  diminishes  the 
number  of  the  teeth  ;  and  in  the  end,  the  future  face  is  thus  given 
a  disagreeable  shape.  The  nose  sinks  downwards  and  backwards, 
and  the  middle  portion  of  the  maxilla  superior  has  the  appear- 
ance as  if  it  had  been  driven  backwards;  the  normal  rotundity 
of  this  portion  of  the  countenance  is  exchanged  for  flatness. 
The  shortened  and  Ijroken  dental  arch  presents  an  unsightly,  if 
not  repulsive,  appearance  when  the  mouth  is  opened.  The 
shortened  antero-posterior  diameter  of  the  buccal  cavity  deterio- 
rates the  voice.  These  are  valid  reasons  for  preserving  the  pre- 
maxillary bone;  if,  however,  the  labial  defect  cannot  otherwise  be 
closed,  the  bone  should  be  removed.  This  may  be  done  in  the 
infant  with  a  pair  of  scissors;  yet,  if  the  operation  be  done  after 
ossification,  bone  forceps  will  be  needed  for  the  division  of  the 
nasal  septum  to  which  the  bone  is  attached.  Should  much 
bleeding  follow  the  removal,  this  may  be  arrested  by  cauterizing 
with  tlie  thermal  cautery. 

For  retention  and  preservation  of  the  premaxillary  bone  one 
of  the  following  methods  may  be  chosen :  (1)  From  the  nasal  sep- 
tum close  to  the  bone,  Blandin  excised  a  V-shaped  portion,  whereby 
the  septum  could  be  shortened;  the  bone  is  then  crowded  back- 
wards into  the  gap  between  the  superior  maxillary  bones.  Bruns 
treats  the  premaxillary  bone  in  a  manner  similar  to  Blandin's 
method.  As  aid  in  this  work,  and  to  control  ])iemorrhnge,  a 
strong  thread  passed  through  the  partition  before  and  behind 
the  excision  may  be  tied,  so  as  to  aid  in  the  closure  and  also  to 
prevent  bleeding  from  the  vessels  opened  in  the  excision.  For 
this  purpose  strong  silver  wire  can  be  used  more  conveniently 


DOUBLE    HARE-LIP.  Oty 

than  silken  thread,  since  tlie  former  can  easily  be  twisted  to  any 
degree  of  tightness,  and  the  twisting  can  be  repeated  at  a  later 
period  if  required.  (2)  Desault  pushed  the  premaxillary  bone 
backwards  into  the  opening  between  the  maxillary  bones.  (3) 
Butcher  of  Dublin  first  fractured  the  supporting  sej)tum,  and 
then  he  forced  the  bone  backwards.  In  the  announcement  of 
his  method  of  operating,  Butcher  claims  originality  for  what 
Hueter  pronounces  not  new,  but  old  work  (and  on  this  point  the 
writer  would  add  that  in  such  assumption  Butcher  held  place 
among  a  vast  number  of  so-called  discoverers  and  inventors), 
(4)  The  mucous  coating  maj''  be  separated  on  each  side  from  the 
unossified  or  ossified  septum,  and  then,  a  section  having  been 
excised  from  the  latter,  the  bone  is  thrust  back  into  the  room 
thus  made  for  it,  and  a  suture  may  be  thrown  around  the  wound 
in  the  septum,  if  there  be  excessive  bleeding.  (5)  Esmarch  trims 
the  sides  of  the  premaxillary  bone,  and  then  forces  it  into  the 
gap  behind;  he  thus  hopes  to  favor  subsequent  union  of  the  raw 
surface  to  the  maxilla  superior,  for  it  has  frequently  been 
observed  that,  although  the  bone  be  forced  back  into  the  gap,  it 
does  not  become  adherent,  but  remains  movable  afterwards;  and 
in  such  case,  the  teeth  would  be  functionally  nearly  valueless. 
The  objection  to  trimming  the  sides  of  the  premaxillary  bone  is 
that  one  or  more  dental  germs  might  be  injured.  Of  the  plans 
mentioned,  the  author  advises  that  in  which  the  mucous  coating 
is  uplifted,  and  the  intermediate  structure  cut  out  as  far  as 
required,  and  then  the  bone  is  to  be  forced  backwards. 

Another  complication  of  this  form  of  hare-lip  is  the  ill  posi- 
tion of  the  nasal  wings,  and  the  flaring,  funnel-like  form  of  the 
nostrils,  which  results  from  such  alar  malposition.  As  means  to 
correct  this,  Blasius  used  a  quill  or  brace  suture,  which  is  placed 
on  each  side  of  the  nose  and  included  in  sutures,  which  main- 
tain compression.  Bruns  uses  a  loop  of  thread,  which,  suture- 
like, including  the  alne  and  septum,  corrects  the  obliquity  of  the 
former.  Again,  the  writer  has  found  that  this  work  may  be  done 
by  making  raw  the  portion  of  the  ala  at  its  attachment  to  the 
lip,  also  the  adjacent  side  of  the  pedicle  of  the  sub-septum;  and 
then  uniting  the  raw  surfaces  by  sutures,  the  form  of  the  nostril 
can  be  rectified  or  much  improved. 

The  order  in  which  this  work  should  be  done,  after  the  child 
has  been  anaesthetized,  is  first  to  place  backwards  the  premax- 
illary bone  by  one  of  the  methods  previously  described,  and  then 
to  trim  the  margins  of  the  cleft  in  the  manner  before  given  for 


580  MolTH    AND    ORAL    CAVITY. 

the  treatment  of  uncomplicated  double  hare-lip.  Two  lateral 
flaps  should  be  formed,  which  are  to  be  united,  as  they  hang 
pendent.  The  intermediate,  angular,  labial  islet  should  be 
trimmed  and  saved,  if  it  can  be  ulili7,ed  in  the  closure.  The  lip 
should  be  detached  from  the  jaw  on  each  side,  so  as  to  facilitate 
lateral  sliding.  If  the  material  be  scant,  there  will  be  much  dif- 
ficulty in  a[)proximating  and  uniting  tlie  sides;  and  to  k-s.sen 
tension,  Roux  applied  a  bandage  so  as  to  include  the  united  parts 
and  lessen  tlieir  tightness;  and  to  accomplish  the  same,  Heurte- 
loup  and  Boeckel  include  the  parts  in  a  deep  suture,  which  les- 
sens the  tension.  Along  with  such  suture,  supporting  adhesive 
strips  may  be  used,  applied  in  the  manner  before  described. 
The  nostrils  are  next  to  be  rectified  by  means  of  lateral  com- 
presses, or  the  looped  transfixing  suture  before  referred  to.  The 
work  of  closing  the  wounded  parts  is  now  to  be  completed  by  the 
use  of  as  many  sutures  as  will  effect  coaptation.  Metallic  suture 
should  be  employed  in  all  this  work,  since  it  irritates  less  tlian 
silk,  and  by  twisting  the  wire,  in  place  of  tying  it,  any  degree  of 
tension  can  be  obtained  which  is  desired. 

The  time  wlien  tlie  sutures  should  be  removed  should  be 
longer  after  this  operation  than  in  any  other  case  of  liare-lip, 
since  there  is  danger  of  the  parts  tearing  asunder,  the  rea.son  of 
this  depending  on  two  causes,  viz.,  the  thinness  of  the  jjarts,  and 
the  pressure  of  tlie  premaxillary  bone.  In  niany  cases  of  com- 
plicated double  hare-lip  the  parts  are  atrophied  and  are  not  thick 
enough  to  bear  the  strain  of  the  sutures  or  the  pressure  of  the 
premaxillar}' bone,  against  which  the  lip?  rest  after  the  closure. 
This  tension,  or  rather  distension,  continue?  after  the  sutures 
have  been  removed,  and  although  union  of  the  two  sides  may 
have  been  obtained,  the  pressure  against  them  from  behind  con- 
tinuing to  act,  they  may  finally  separate  completely  or  only  j^nr- 
tially.  Partial  union  is  much  better  than  complete  solution;  in 
the  latter  case  the  condition  is  worse  than  prior  to  the  operation; 
but  when  some  union  has  been  obtained  it  gives  much  aid  in  the 
work  afterwards  undertaken  to  obtain  complete  union. 

The  question  sometimes  arises  whether  in  case  there  has  been 
failure  to  get  union,  it  is  better  to  reoperate  at  once,  or  to  delay 
until  the  i)arts  have  healed  and  the  inftnit  has  become  stronger. 
The  experience  of  the  writer  is  highly  unfavorable  to  reoperating 
at  once,  in  case  there  has  beoii  failure  to  get  union  at  the  fiist 
operation;  though  he  has  attempted  this  in  a  few  ca.ses  in  which 
such  failure  had  occurred,  in  but  one  instance  did  the  second" 


DOUBLE    HARE-LIP.  681 

operation  end  successfully.  Hence,  the  writer  would  differ  from 
Sedillot,  who  advises  to  reoperate  as  soon  as  failure  to  obtain 
union  has  occurred.  According  to  the  writer's  experience,  the 
tissues  which  have  recently  been  operated  on  and  torn  asunder 
are  abnormally  fragile  and  are  very  apt  to  separate  again  should 
they  be  reclosed;  it  is  better  to  wait  until  the  parts  have  become 
solidified,  as  they  will  do  if  time  be  allowed  for  them  to  heal. 
Not  less  than  three  months  (and  even  six  months  is  better)  should 
elapse  before  the  next  operation.  If  this  course  be  pursued,  the 
chances  of  success  after  the  second  operation  will  be  much 
increased. 

The  writer  would  warn  against  the  error  sometimes  committed 
of  prolonging  the  work  by  too  much  attention  to  the  minute 
details  of  the  operation;  leading  operators,  as  Stokes  and  Hueter, 
counsel  expedition  in  the  work.  In  hastening  through  the  work, 
and  by  obeying  the  second  term  of  tuto,  cito  et  jucunde,  the  oper- 
ator will  comply  with  and  emphasize  the  first  and  third;  that  is, 
celerity  will  contribute  to  safety  and  success. 

After  successful  closure  lias  been  thus  obtained,  some  addi- 
tional work  is  commonly  required  to  overcome  certain  defects 
which  remain;  and  here,  as  in  case  of  failure  of  the  primary 
operation,  the  temptation  is  great  to  do  this  immediately  ;  but  as 
delay  was  needed  in  the  former  case,  so  it  is  equally  necessary  in 
this  one;  one  should  wait  for  three  months  at  least,  before  using 
the  knife  again.  And  should  the  defects  be  slight,  it  will  often 
occur  that  after  a  short  period,  they  will  become  less  conspicuous; 
in  fact,  the  appearance  will  become  so  much  better  that  the 
parents  may  decline  any  further  operative  amendment. 

Surgical  services  are  sometimes  demanded  in  cases  in  which 
an  operation  has  been  done  some  years  before  for  the  relief  of 
hare-lip,  and  in  which  the  result  obtained  was  unsatisfactory ; 
and  another  operation  is  solicited.  The  remaining  defect  may 
be  a  V-gap,  uneven  opposition  of  the  two  sides  or  the  exposure  of 
too  large  a  surface  of  raucous  membrane;  or  an  unsightly  scar 
records  the  imperfect  work  which  has  been  done.  Again,  with- 
out the  scar  being  very  conspicuous,  it  may  contract  lengthwise, 
and  thus  uplift  and  evert  the  border  of  the  lip.  Besides  these 
labial  irregularities,  there  may  remain,  after  the  operation,  a  flar- 
ing obliquity  of  one  nostril,  which,  if  unrelieved,  will  remain  as 
an  unsightly  feature.  In  each  of  these  conditions,  a  carefully 
studied  piece  of  surgical  work  will  be  rec[uired  to  efface  or  improve 
the  condition.     And,  desj^ite   the  most   careful   and   intelligent 


582  MOUTH  AND  ORAL  CAVITY. 

attempt,  the  result  obtained  is  often  far  from  being  a  joy  to  the 
patient;  on  the  contrary,  it  is  often  a  disappointment;  for  correc- 
tion of  tlio  errors  and  jnissteps  made  by  nature  in  her  work  of 
molding  the  embryo,  is  far  more  easily  done  at  the  first  operation, 
than  in  cases  in  which  nature's  errors  liave  been  intensified  l)y 
the  blunders  of  unskilled  art.  Hence  it  is  prudent  to  abridge 
hope  and  limit  promise  in  this  secondary  reparative  work. 

The  most  usual  defect  of  those  mentioned,  requiring  re{)air,  is 
that  in  which  the  V-gap  is  combined  with  an  unsiglitly  vertical 
scar;  the  latter,  by  its  paleness,  contrasting  with  tlie  adjacent  nor- 
mal skin.  To  correct  this  an  operation  may  be  done,  consisting, 
in  tlie  main,  of  three  acts.  By  means  of  a  horizontal  cut,  a 
hanging  loop-like  bridge  of  tissue  can  be  formed,  from  the  border 
of  the  lip,  at  the  site  of  the  V-gap.  This  incision  must  be  made 
in  the  horizontal  plane  and  include  enough  tissue  to  retain  its 
vitality.  Next  tlie  scar  is  to  be  excised  by  two  vertical  cuts 
which  closely  include  it;  and  these  incisions  sljould  be  continued 
upwards  on  each  side  of  the  nose,  at  first,  close  to  the  ala;  and 
then  each  must  diverge  from  tlie  naso-labial  sulcus  laterally. 
The  upper  portion  of  these  incisions  will  be  in  the  form  of  a  Y,  of 
which  the  two  upper  branches  should  rapidly  diverge  as  they 
ascend;  and,  if  need  be,  the  lateral  portions  are  to  be  dissected 
from  their  subjacent  attachment,  wdiile  the  median  upper  por- 
tion is  to  remain  fixed  in  its  site.  Closure  of  the  wounds  is  to 
begin  from  above,  and  in  doing  this,  the  sides  must  be  drawn 
down  and  fixed  to  the  intermediate  portion  by  sutures,  in 
such  a  manner  as  to  lengthen  the  sides  and,  consequently,  the 
height  of  the  lip.  To  aid  in  this  fixation,  a  transfixing  pin 
should  be  used,  which  will  pass  through  the  depressed  sides  and 
the  intermediate  portion.  Besides  this  twisted  suture,  one  or 
more  knotted  metallic  ones  should  be  used  to  complete  the  clo- 
sure of  the  vertical  wound.  The  horizontal  swinoinir  bridiie  is 
next  to  be  folded  on  itself,  and  closed  by  a  suture  which  will 
fasten  it,  so  folded,  to  the  parts  above.  If  these  several  cuts  be 
properly  done,  the  lip  will  be  vertically  lengthened,  and  the  V- 
defect  replaced  by  the  normal  tubercle. 

In  case  the  median  gap  is  the  only  defect  requiring  removal, 
then  the  filling  up  of  this  defect  may  be  done  by  an  incision  of 
V-form  through  the  entire  thickness  of  the  lip,  and  stopping,  on 
each  side,  at  least  one  line  above  the  labial  border  ;  and  this  may 
be  done  in  opposite  ways.  In  one  way  the  cut  is  shapen  as  an 
inverted  V,  thus  ^\;  this  incision  allows  the  forcing  downwards 


DOUBLE    HARE-LIP.  583 

of  the  angular  portion  included  between  the  lateral  cuts,  and 
the  retention  there  of  this  part  by  proper  sutures;  thus  done, 
there  is  effacement  of  the  gap;  or  it  can  be  done  in  a  manner 
quite  opposite  to  this,  viz.,  with  a  cut  of  V  form,  in  which  tlie 
inferior  angle  will  reach  nearly  to  the  labial  margin.  Such  a 
cut  will  allow  of  tlie  forcing  downwards  of  the  Y  against  the  bor- 
der, and  its  maintenance  there  by  means  of  proper  sutures.  By 
one  of  these  ways,  preferably  by  that  of  the  ^v-^rm,  the  gap  may 
be  filled. 

The  exposure  of  too  broad  a  stripe  of  mucous  membrane  may 
arise  from  the  ill  placing  of  the  bridge  which  is  used  to  fill  the 
median  gap.  And  a  defect,  almost  as  striking,  is  where  dermal  tis- 
sue occupies  the  normal  site  of  mucous  membrane.  These  defects 
are  difiicult  of  correction;  their  avoidance  at  the  primary  opera- 
tion is  an  easier  matter;  here,  as.  elsewhere,  the  preventive  ounce 
far  outweighs  the  corrective  pound.  As  each  case  under  this 
head  has  its  special  characteristics,  the  procedures  for  correction 
are  so  diverse  that  it  is  impossible  to  lay  down  special  rules  for 
the  work;  the  ingenuity  of  the  surgeon,  if  he  be  fertile  in  expedi- 
ents, will  devise  a  plan  suited  to  the  individual  case.  And  tlie 
writer  would  say  that  the  essays  which  he  has  made  in  this  field, 
though  contenting  the  patient,  have  not  been  satisfactory  to  him- 
self; indeed,  the  operation  accomplished  rather  a  change  than 
an  effacement  of  the  deformity;  old  lines  of  ugliness  were  super- 
seded by  new  ones  possibly  less  ugly. 

A  defect,  sometimes  arising  from  an  operation  on  hare-lip, 
is  an  eversion  of  the  middle  portion  of  the  lip,  and  continued 
exposure  of  the  front  teeth.  To  prevent  such  eversive  retractile 
action  and  consequent  shortening,  Soupart  of  Ghent,  in  1859, 
advised  to  cross  the  incision  made  by  a  second  one,  at  right 
angles  to  the  first  one.  This  plan  is  in  conformity  with  a 
principle  which  Soupart  has  verified,  that  a  straight  linear  wound 
will  contract  less  if  it  be  intersected  by  other  cuts.  In  fact,  Sou- 
part  asserts  that  he  lengthened  the  short  side  of  a  labial  cleft  by 
such  intersecting  incisions.  The  crossing  cut  need  not  pass 
through  the  entire  thickness  of  the  lip. 

In  case,  however,  such  vertical  shortening  with  eversion  of  the 
border  is  not  corrected  by  a  cross  incision  made  horizontally  or 
obliquely, then,  in  the  gaping  space  thus  made  by  incision,  a  pedi- 
cled  flap,  uplifted  from  the  adjacent  surface,  may  be  turned 
around  and  inserted  in  the  opening  made.  The  cut,  into  which 
the  insertion  is  made,  sliould  be  deep,  yet  not  pass  through  the 
entire  thickness  of  the  lip. 


584  MOUTH    AND    ORAL    CAVITY. 

The  last  defect,  for  which  corrective  work  may  be  demanded, 
is  that  of  wide  nostril,  oblique  flaring  wing,  and  sinking  of  the 
end  of  the  nose.  The  corrective  work,  here  to  be  done,  is  to  uplift 
the  ala  nasi  and  bring  it  nearer  to  the  sejitum.  To  accomplish 
this,  an  excision  of  tlie  tegumentary  surface  of  the  inferior  outer 
an<rle  of  the  nostril  is  to  be  made,  and  then  the  ala  is  to  be  forced 
inwards  towards  the  septum,  and  retained  there  by  metallic 
suture.  This  work  of  rectification  is  seldom  required  on  more 
than  one  side,  and  this  is  commonly  the  left  side.  After  the 
operations  for  hare-lip,  if  the  child  can  nurse  it  should  be  per- 
mitted to  do  so;  for  if  it  be  withdrawn  from  the  breast  until  the 
wounds  heal,  it  sometimes  forgets  the  act  of  seizing  and  holding 
the  nipple.  It  can  readily  nurse  after  the  operation,  provided 
the  nostrils  are  patent;  but  if  these  be  closed,  as  sometimes 
occurs,  then  the  child  must  be  nourished  from  a  spoon,  or  other 
means  used  in  the  nursery.  And,  as  a  severe  assault  is  made  on 
the  child  by  the  operation,  it  is  a  matter  of  the  utmost  importance 
that  its  nutrition  should  be  well  maintained. 


CHAPTER     XVIi. 


LABIAL    GROWTHS. 


The  neoplastic  developments  which  have  location  in  the  lips 
will  next  be  considered;  and  as  the  labial  structure  is  a  composite 
of  many  elementary  tissues,  it  is  a  favorable  site  for  almost  all 
varieties  of  new  growtli;  and  such  neoplasm,  according  to 
histologic  origin,  may  be  named  vascular,  follicular,  epithelial  or 
of  connective  tissue  type. 

The  statistician,  who  has  collected  long  series  of  tumors,  finds 
that  vascular  growths  occur  oftenest  in  the  head;  Porta  found,  in 
a  series  of  .one  hundred  and  fifty-one  vascular  tumors,  that  one 
hundred  and  seven  were  seated  on  the  head,  eighty-nine  of  these 
were  situated  on  the  face,  and,  of  these,  ten  belonged  to  the  labial 
region.  In  a  series  of  fifty-six,  .collected  by  Lebert,  twenty -six 
were  on  the  head;  and  seven  of  these  were  on  the  lips.  The 
upper  and  lower  lips  have  equal  share  in  furnishing  site  for  the 
vascular  neoplasm.  From  the  writer's  observation,  the  growth 
occurs  much  oftener  in  the  female  than  in  the  male.  Bouisson 
reports  the  operation  of  ten  cases,  all  of  which  were  in  females. 
It  may  occur  at  the  angle  of  the  mouth,  and  then  both  lips  are 
implicated. 

The  labial  angioma,  analogous  to  that  seen  elsewhere,  may 
be  superficial  and  confined  to  the  surface;  or  the  entire  thickness 
of  the  lip  may  be  occupied  by  the  growth,  and  between  these 
many  gradations  occur.  Arterioles  and  venules  concur  in  the 
development  of  these  growths;  and,  where  the  tumor  involves 
the  deeper  labial  structure,  it  has  the  property  of  swelling. 
This  form  is  known  as  the  erectile  vascular  growth;  and,  from  the 
fact  that  in  this  form  dilated  spaces  are  found  which  are  filled 
with  blood,  this  species  is  sometimes  denominated  the  cavernous 
tumor. 

The  cavernous  or  erectile  tumor  is  more  frequent  in  the  lip 
than  the  superficial  forms;  it  begins  as  a  small  point,  as  a  rule, 
and  this  may  remain  stationary,  and  afterwards  rapidly  grow, 
38  (585) 


586  LABIAL    GROWTHS. 

extending  into  and  involving  the  adjacent  structure  of  the  cheek. 
It  presents  a  livid  bluish  aspect,  and  enlarges  during  any  expira- 
tory effort  of  tlio  patient.  Tlie  e})iderin  conceals  the  color  on  the 
side  of  the  skin;  and  the  livid  hue  is  more  apparent  on  the 
internal  side. 

During  infancy  and  youth  the  erectile  angioma  ma}^  continue 
to  grow  until  it  reaches  considerable  dimensions;  but  in  adult 
life  and  in  the  aged,  such  growth  is  absent,  or,  at  least,  very  slow. 
And  in  a  few  cases  the  tumor  has  receded,  and  spontaneously 
disappeared.  Such  fortunate  event  is  so  rare  that  it  is  prudent  to 
eliminate  it  from  the  problem  of  the  prognosis  of  this  growth. 

This  tumor  is  absolutely  painless  so  long  as  the  bounding 
skin  or  mucous  membrane  remains  intact;  it  is,  liowever,  not  an 
uufrequent  occurrence  that  the  external  surface,  through  accident 
or  otherwise,  becomes  the  site  of  abrasion  or  fissure;  and  such 
opening  permits  the  escape  of  blood  from  the  broach;  and  thus 
liaimorrhage  may  recur  and  debilitate  the  subject.  Such  luemor- 
rhage  can  also  originate  from  death  and  sloughing  of  the  surface 
of  the  growth,  the  condition,  here,  being  similar  to  that  seen  in 
ulceration  arising  from  a  varicosed  condition  of  the  lower  extrem- 
ities. This  ulcerated  condition  of  the  angiomatous  lip  being  a 
source  of  continued  irritation,  there  may  result  malignant  disease, 
similar  to  what  occurs  in  the  leg.  And,  in  such  a  case,  there  is 
a  commingling  of  the  elements  of  cancer  and  vascular  growth. 
Such  disease,  which  has  been  observed  by  Bouisson,  it  is  needless 
to  say,  is  far  graver  than  normal  angioma;  the  treatment  of  the 
latter  must  vary  from  the  former. 

Another  form  of  labial  angioma  is  one  which  is  limited  in 
volume,  and  situated  on  the  mucous  border.  This  is  non-erectile, 
constant  in  form,  and  is  remarkable  for  its  dark  livid  or  purplish 
hue,  resembling  in  color  an  undried  prune.  In  appearance  it  is 
analogous  to  melanotic  cancer;  yet  it  is  wholly  benign.  Tin's 
growth  occurs  oftenest  in  the  female's  lij),  and  is  a  source  of 
trouble  from  its  unsightliness. 

As  the  form  and  appearance  of  the  lip  may,  according  to  their 
character,  render  the  face  attractive  or  repulsive,  hence  the 
angiomatous  development  here  becomes  of  far  more  importance 
than  it  would  if  situated  in  other  parts  of  the  body;  therefore 
the  removal  of  such  deformity  in  the  adult  is  urgently  solicited; 
and  if  in  an  infant,  the  diligence  of  affection  is  yet  more  importu- 
nate in  its  demands  for  surgical  aid. 

Treatment. — Many  means  may  be  resorted  to  for  the  cure  of 


LABIAL    GROWTPIS.  587 

labial  angioma;  a  cardinal  principle,  which  should  guide  in  the 
work,  is  to  leave  as  small  a  scar  as  possible;  were  it  done  other- 
wise, the  patient  would  only  exchange  one  ill  for  another.  The 
treatment,  also,  should  vary  according  to  the  grade  of  the  vascu- 
lar growth. 

In  case  the  growth  is  of  the  most  superficial  species,  in  which 
the  affected  structure,  consisting  of  intercommunicating  capillaries, 
has  been  named  telangiectasis,  the  most  appropriate  treatment  is 
cauterization  by  the  actual  or  potential  method.  The  simple 
thermal  cautery  will  accomplish  the  work ;  but  care  must  be  used 
not  to  destroy  the  surface  too  deeply;  the  metallic  cautery  should 
be  passed  once  or  twice  over  the  affected  surface,  and  this  should 
be  repeated  after  the  destroyed  surface  is  detached.  The  work 
can  also  be  done  by  means  of  fuming  nitric  acid,  care  being  used 
that  the  acid  does  not  enter  the  mouth. 

Should  the  vascular  growth  reach  deeper,  then  attacking  it 
superficially  will  be  insufficient.  The  most  conservative  plan 
which  then  can  be  pursued  is  that  of  simple  compression.  Boyer 
reports  that  he  thus  cured  a  labial  vascular  growth.  To  do  this, 
a  strip  of  India  rubber  should  intervene  between  the  lip  and 
the  teeth,and,  on  the  outside,  compression  may  then  be  main- 
tained by  an  elastic  bandage;  or,  to  a  head-dress,  a  compressive 
appliance  m.ight  be  attached  anteriorly.  As  the  intent  of  such 
appliance  is  to  lessen  the  blood  supply  to  the  lips,  the  work  would 
be  materially  aided  by  continued  pressure  maintained  on  the 
facial  arteries,  where  they  lie  on  the  maxilla  inferior. 

The  labial  angioma  might  be  removed  in  the  infant  by 
inoculation  with  vaccine  virus ;  a  serious  objection  to  this  method 
is  that  it  entails  the  permanent  marks  which  characterize  the 
vaccine  scar.  Another  grave  objection  is  the  long  period  of 
suppuration    which   it  compels  the    patient    to   pass   through. 

Pustulation  with  tartar  emetic  will  accomplish  the  same 
regressive  change  in  the  vascular  structure;  and  an  ointment  of 
ipecacuanha  acts  similarly. 

The  tumor  may  be  brought  to  a  permanent  standstill  by 
injecting  into  it  some  coagulating  fluid,  as  a  solution  of  a  salt  of 
iron,  or  some  vegetable  astringent,  as  the  tincture  of  nut-galls.  In 
this  way  the  blood  content  may  be  coagulated  and  remain,  as  it 
were,  fossilized,  an  unchanging  component  of  the  labial  structure. 
Besides  the  peril  that  such  fluid  might  overleap  the  boundaries 
of  the  growth  and  enter  the  circulation,  it  is  unsatisfactory  in 
another  way,  viz.,  that  the  mucous  surface  may  remain  uneven 


588  LABIAL    (illOWTHS. 

and  discolored.  Ileiu-e  other  methods  are  preferable  to  that  of 
coagulation. 

Ainetlu)d  whicli  might  be  used  is  thermal  cauterization,  done 
by  means  of  needles,  which,  heated  to  red  heat,  are  tlirust  into 
the  angioma  and  retained  there  until  they  destroy  a  thin 
stratum  of  structure  contiguous  to  them.  This  plan  should  be 
proceeded  with  slowly  and  repeated  several  times  until  the  work 
is  completed.  If  the  operator  has  had  some  experience  in  this 
method,  he  will  be  able  to  thus  satisfactorily  remove  or  reduce 
the  vascular  growth;  but  in  his  first  essays  he  usually  exceeds  or 
falls  short  of  the  proper  measure. 

Reduction  may  be  done  by  transfixing  the  vascular  structure 
by  pins,  and  then  including  the  pins  in  constricting  ligature, 
the  constriction  to  be  maintained  until  the  circulation  is  arrested. 

By  any  of  the  methods  mentioned,  the  angioma  may  be 
reduced  in  volume  and  often  cured;  still,  it  not  unfrequcntly 
occurs  that  small  sections  of  the  growth  remain,  whence  regrowth 
may  originate,  and  the  angioma  subsec[uently  reappear.  Hence 
some  certain  and  trustworthy  plan  is  desirable;  and  this  is  found 
in  excision.  By  excision,  the  writer  has  frequently  removed  the 
labial  angioma,  in  which  the  growth  occupied  the  whole,  or  the 
greater  part,  of  the  thickness  of  the  lip.  The  scalpel  makes  few 
mistakes  when  wielded  by  the  trained  hand.  Excision  may  be 
done  by  sections,  or  the  entire  growth  may  be  removed  by  a  cir- 
cumscribing incision. 

In  partial  excision,  cuneiform  sections  of  the  structure  are  to 
be  removed,  and  the  intermediate  w'edge-shaped  sections  of  struc- 
ture which  remain  are  to  be  united  by  sutures.  One,  who  has 
not  performed  such  cuneiform  excision,  should  be  warned  not  to 
form  gaps  too  near  each  other,  else  he  will  find  difficulty  in 
effecting  complete  closure  of  the  surface,  for  it  is  apparent  that 
the  remaining  triangular  portions  of  structure  cannot  simulta- 
neously be  displaced  in  two  directions;  and  to  avoid  error  in 
the  closure,  it  is  better  to  close  each  gap  as  soon  as  it  is  formed. 
The  experience  of  the  writer  in  such  excision  and  closure  has 
taught  him  that,  if  the  work  is  done  otherwise,  it  is  difficult  to 
estimate  correctl}"  the  amount  which  should  be  excised;  but,  done 
as  here  indicated, besides  satisfactory  closure  of  the  opened  surfaces, 
the  loss  of  blood  will  also  be  reduced  to  the  smallest  amount. 

Inasmuch  as  any  portion  of  the  remaining  tumor  may  con- 
tinue to  grow,  a  more  certain  method  is  to  completely  excise 
the  vascular  structure.     In  this  work  the  entire  thickness  of  the 


LABIAL    CYSTOMA.  589 

li23  should  be  excised;  and  this  is  practicable  in  cases  in  which 
the  growth  is  not  of  large  volume;  but  if  the  greater  portion  of 
the  lip  be  involved,  the  treatment  should  be  in  accordance  with 
some  one  of  the  conservative  plans  which  have  hitherto  been 
explained.  The  question  may  be  asked  whether  it  would  not  be 
more  proper  to  spare  the  dermal  side  of  the  lip,  provided  the 
angioma  occupies  cliieti}^  the  opposite  side;  the  objection  is  that, 
thus  done,  there  will  be  left  a  wound  opening  into  the  mouth. 
Or,  if  an  attempt  be  made  to  close  the  wound  by  a  suture  in  the 
inner  side,  the  result  wottld  1  le  a  pouting  process  on  the  outside, 
which  would  continue  as  a  lasting  deformity.  These  are  valid 
reasons  for  sacrificing  the  entire  thickness  of  the  lip,  and  they 
are  further  fortified  by  the  facility  which  is  given  for  accurate 
closure  of  the  wound  when  the  work  is  thus  done. 

Total  excision  is  best  done  when  the  scalpel  follows  the  line 
which  separates  the  vascular  from  the  normal  structures.  A 
little  observation  and  study  will  enable  the  operator  to  do  this, 
and  excision,  thus  done,  will  cause  but  slight  bleeding,  for  the 
growth  receives  and  returns  its  supply  of  blood  through  but  few 
arteries  and  veins.  If,  however,  the  incisions  enter  or  traverse 
the  angiomatous  structure,  then  there  will  be  profuse  bleeding 
from  the  wound.  It  is  rare  that  ligatures  are  required  to  check 
the  bleeding.  The  liEemorrhage  can  be  reduced  to  a  minimum 
by  torsion  and  careful  apposition  by  sutures. 

In  case  the  growth  is  so  extensive  as  to  compel  the  operator 
to  enter  tlie  buccal  wall,  then  the  dermal  side,  if  possible,  should 
not  be  opened,  the  removal  being  done  wholly  on  the  inside;  and 
in  this  work,  should  an  extended  recess  or  pocket  be  formed 
between  the  mucous  membrane  and  the  outer  wall,  then  the 
cavity  formed  should  be  slit  to  its  bottom,  so  that  excreta  or  other 
material  may  not  find  lodgment  there. 

Small,  isolated  angioma  seated  on  the  border  of  the  lip,  such 
as  the  prune-colored  species  early  mentioned,  is  best  disposed  of 
by  cuneiform  excision  done  with  scissors;  and  then,  if  a  consid- 
erable notch  be  formed,  it  may  be  closed  by  suture. 

Labial  Cystoma. — Cystic  growth,  commonly  of  small  dimen- 
sions, sometimes  develops  beneath  the  mucous  surface  of  the  lips. 
Such  growth  is  somewhat  flattened  in  form,  and  rarely  exceeds 
the  size  of  a  pea  in  volume.  The  content  resembles  inspissated 
mucus,  and  is  viscid  and  gelatinous  in  character.  The  covering 
wall  is  transparent  and  so  thin  that  the  character  of  the  content 
is  distinguishable  through  it.     If  this  wall  be  opened,  the  con- 


690  LABIAL    GROWTHS. 

tent  escapes,  and  the  cyst  temporarily  disappears;  yet  it  soon 
reforms  and  i)resents  the  same  appearance  as  before.  Besides 
the  small  cysts  here  described,  those  of  much  larger  volume  have 
been  observed.  And  as  these  were  multilocular  in  structure,  they 
probably  arose  from  the  fusion  of  two  or  more  simple  C3'sts. 

Whether  simple  or  compound,  the  labial  cyst  doubtless  arises 
from  closure  of  one  or  more  mucous  follicles,  and  the  retention 
and  accumulation  of  the  secreted  content. 

Such  cyst  is  painless,  yet  its  presence  is  disagreeable,  inasmuch 
as  the  tip  of  the  tongue  falls  into  the  habit  of  often  visiting  the 
part,  a  fact  which  the  writer  can  testify  to  from  subjective  knowl- 
edge. And  this  becomes  especially  anno^'ing  if  the  cyst  is 
large,  as  in  the  cases  cited  above;  in  fact,  such  development  would 
visibly  deform  the  lip. 

This  follicular  cyst  is  innocent  in  character,  and  free  from 
any  malignant  tendency;  yet,  as  the  lip  is  so  often  the  site  of 
epithelial  cancer,  any  growth  in  it  awakens  suspicion,  is  a 
source  of  anxiety,  and  soon  leads  the  possessor  to  seek  medical 
counsel.  The  physician  or  surgeon  can  quickly  allay  the 
patient's  fears  by  assurance  of  the  harmlessness  of  the  growth; 
if,  however,  the  patient  has  the  misfortune  to  fall  into  the 
clutches  of  the  cancer  quack,  after  a  period  of  torture  with 
caustic  applications,  he  finds  himself  cured,  and  his  case  is  her- 
alded among  the  laity  as  a  case  of  cancer  cured  without  tlie  use 
of  the  knife. 

The  proj^er  treatment  for  this  cystic  growth  is  to  insert  a  fine 
tenaculum  beneath  it,  and,  having  uplifted  the  cyst,  excise  with 
curved  scissors.  Or  the  lip  may  be  so  compressed  as  to  2>usli  the 
growth  outwards,  when  its  removal  with  scissors  alone  is  easih^ 
done;  in  fact,  in  this  way  the  writer,  standing  before  a  mirror, 
removed  such  a  C3^st  from  his  lower  lij),  and  his  report  on  the 
work  is  that  it  was  less  difficult  than  painful;  and  the  lesson 
derived  from  his  experience  w'as  what,  no  doubt,  many  a  reader 
can  bear  witness  to,  that  the  most  accurate  knowledge  of  a  dis- 
ease is  derived  from  being  its  subject;  for  while  books  furnish  the 
changing  doctrines  of  disease,  and  clinical  observation  often 
illustrates  the  same  enigmatically,  yet  personal  experience  of 
suffering  stereotypes  the  same  on  the  page  of  memory  as  knowl- 
edge unembarrassed  with  doubtful  theorv. 

Labial  Cancer. — The  pathologist  who  divides  the  chapter  of 
cancer  into  four  or  five  sections,  may  find  representatives  of  these 
different  species   in   the   labial  region;   but  the  infrequency  of 


LABIAL    CANCER.  591 

encephaloid,  cicatrizing,  colloid  and  melanoid  cancer  on  the  lips, 
renders  a  consideration  of  the  latter  unnecessary  here.  The  form 
commonly  occurring  in  the  lip  is  that  which  has  received  several 
names,  viz., local  cancer,  cancroid  epithelial  cancer  or  epithelioma. 
The  name  of  epithelioma  was  given  it  by  Hannover,  in  1852,  and 
this  name  is  derived  from  the  circumstance  that  the  main  con- 
stituent of  the  growth  is  the  epithelial  element  which  forms  the 
outer  investment  of  the  lip;  and  so  well  is  the  name  affixed  to  the 
page  of  nomenclature,  that  the  word  is  beginning  to  have  a  place 
in  the  language  of  the  learned  layman.  The  name  Cancroid  had 
its  defender  in  Lebert,  and  after  flourishing  transiently,  seems  to 
have  run  through  youth  and  maturity  and  is  now  verging  into 
obsolete  age,  whence,  if  it  follows  the  usual  fate  of  words,  it  must 
soon  find  its  humble  place  in  the  glossary  which  is  appended  to 
works  on  nomenclature. 

Commencement  and  Course. — The  labial  epithelioma  commences 
by  an  augmentation  of  the  epithelial  investment  of  the  lip,  and 
this,  as  a  rule,  is  the  lower  lip ;  the  superposed  strata  are  increased 
in  number,  and  the  component  cells  are  augmented  in  volume. 
And  this  cellular  development  occurs  initially  on  the  border  of 
the  lip  where  dermal  and  mucous  epithelium  meet.  This  aug- 
mentation, at  first  slight,  is  jjlainly  apparent  later;  and  this  may 
be  limited  to  a  small  space,  or  it  may  be  spread  along  the  border 
until  it  attains  an  inch  or  more  in  extent,  and  then  the  middle 
portion  of  the  afi'ected  border  is  the  most  elevated,  unless  it  has 
been  lowered  through  ulcerative  action.  The  affected  part  has  a 
whitish  or  grayish  appearance.  This  altered  condition  may 
remain  with  but  slight  change  for  a  long  period;  the  outer  epi- 
thelial stratum  becoming  desiccated  and  of  dark  color,  is  occa- 
sionally detached,  either  by  accident  or  the  patient's  finger,  and- 
then  it  is  soon  replaced  by  a  thicker  stratum. 

Cases  somewhat  akin  to  those  mentioned  are  those  in  which 
the  morbid  growth  is  limited  to  a  small  surface;  the  epithelial 
strata,  forming  a  mold  of  two  or  more  papillas,  continues  to  grow 
without  limit,  and  thus  a  horn-like  growth  is  jjroduced,  which' 
may  attain  dimensions  of  from  a  half  inch  to  an  inch  in  length. 
Such  a  growth  is  formed  of  concentric  strata,  in  the  center  of  the 
base  of  which  is  contained  a  process  of  the  mucous  structure 
which  is  sensitive  and  vascular.  The  presence  of  sulphur,  in 
which  the  growth  is  rich,  and  the  peculiar  odor  arising  when  it  is 
burned,  show  the  identity  of  this  growth  with  horn}'  material,  as 
hair,  nails,  etc.     Such   growth   may  exist   simultaneously  with 


592  l.ABIAL    GROWTHS. 

adjacent  epithelioma,  and  finally  assume  the  malignant  nature  of 
the  contiguous  epitheliomatous  structure. 

Instead  of  the  epithelial  development  of  the  flattened  or  of 
the  horn-like  species  mentioned,  an  equally  common  if  not 
more  frequent  form,  in  which  it  makes  its  advent,  is  that  of  a 
wart,  or  of  a  crack  or  fissure  in  the  border  of  the  lip.  This 
form  is  commonly  in  the  middle  third  of  the  lip,  and  near  or  in 
the  median  line  of  this  portion.  Whether  in  the  form  of  a  raw 
tubercle,  or  a  cleft  in  the  border,  there  is  a  hardness  of  the 
affected  site,  and  this  induration,  alons:  with  increasiuir  tliickness 
of  the  lip,  slowly  enlarges  its  sphere  until  it  occupies  a  greater  or 
less  portion  of  the  lip.  If  the  initial  ])oint  be  a  fissure,  sooner  or 
later  the  sides  of  this  break  down  by  ulceration;  since  the  strata 
of  cells  most  remote  from  their  nutrient  source,  through  inanition, 
perish,  break  down  and  are  detaclied,  there  remains  a  raw 
surface.  And  about  the  tuberculated  site  of  ori2:in,from  analogous 
excessive  cell  growth,  disintegration  ensues.  The  advancing 
malady  in  either  case  is  like  a  cruel  victor  who  both  occupies  and 
destroys,  and  without  rest  pursues  its  march  of  devastation.  The 
cell  product  insinuates  itself,  by  a  species  of  substitution,  into  the 
normal  tissues,  and  ends  by  replacing  the  latter;  a  replacement 
so  complete  that  abnormal  is  substituted  for  normal  tissue,  and 
the  former,  after  a  transient  existence,  dies,  and  there  remains  an 
ulcerated  breach.  The  morbid  growth  may  extend  along  the 
border  of  the  lip  horizontally;  yet  the  infiltration  proceeds  rather 
towards  the  base  of  the  lip.  This  infiltration  is  not  uniform,  the 
substitution  being  more  complete  at  some  points  than  at  others; 
hence  sections  of  undestroyed  structure  may  remain  standing 
alongside  of  the  adjacent  sections  which  have  broken  down; 
thus,  in  time,  there  arises  a  very  irregular  surface;  islets  of  but 
slightly  affected  tissue  border  on  ulcerated  excavations. 

If  the  epitheliomatous  process  be  studied,  it  will  be  seen  that 
it  consists  in  the  development  within  normal  tissue  of  a  structure 
of  which  the  marked  characteristics  are  rapid  growth  and  short 
life;  after  originating  in  some  unexplained  manner,  it  passes 
through  brief  periods  of  youtji,  maturity,  age  and  dissolution. 
If  it  be  examined  by  incision  in  its  mature  state,  it  will  be  found 
much  harder  in  structure  than  the  normal  labial  tissue;  the 
incised  surface  is  marked  by  yellowish  or  greenish  spots,  and  if 
it  be  compressed,  there  will  be  forced  out  a  paste-like  fluid  and 
yellowish  bodies.  If  the  material  thus  extracted  from  the  morbid 
tissue  1)6  microscopically  examined,  it  will  be  seen  to  be  composed 


LABIAL    CAXCER.  593 

of  epithelial  cells,  isolated  or  in  groups,  and  those  in  groups  may 
have  a  concentric  arrangement  which  they  have  retained  from 
their  primitive  molding  around  the  papillae  of  the  mucous  mem- 
brane. Elementary  analysis  discovers  that  the  active  agent  in 
this  destructive  transformation  is  the  epithelial  cell,  and,  along 
with  these  cells,  coexist  bacterial  microphytes,  of  which  the 
agency,  whether  causal  or  passively  contingent,  has  not  been 
determined. 

After  the  labial  epithelioma  has  continued  its  work  of  ulcera- 
tive destruction  to  the  expiration  of  its  lease  of  life,  an  examina- 
tion will  discover  that  the  glands  in  the  space  within  the  inferior 
maxillary  arch  become  enlarged.  When  small,  these  glands  are 
easily  movable;  but  later,  they  become  adherent  to  the  contigu- 
ous structures,  and  finally  the  covering  derm  opens,  and  an  ill- 
formed  pus  is  discharged.  This  pus  is  somewhat  similar  to  the 
material  before  mentioned,  which  can  be  squeezed  from  the 
stroma  of  the  mature  epithelioma.  In  character  the  discharge  is 
similar  to  that  which  is  yielded  by  a  broken-down  gummy 
growth.  The  location  of  such  enlarged  glands  is  near  the  sub- 
maxillary gland,  and,  as  a  rule,  it  is  directly  underneath  the 
affected  portion  of  the  lip;  by  some  abnormal  error,  the  affected 
glands  are  exceptionally  found  an  the  opposite  side;  such  aberrant 
metastasis  the  author  has  now  under  his  observation.  If  the 
lymphatic  glands,  lying  on  the  submaxillary  salivary  gland,  indu- 
rate, swell  and  open,  the  salivar}/-  gland  becomes  infected,  and 
likewise  ulcerates.  The  adjacent  maxilla,  when  reached  by  the 
advancing  infiltration,  becomes  affected;  the  erosion  may  be 
superficial,  or  so  deep  as  to  nearly  divide  the  jaw  and  make  its 
fracture  an  easy  matter.  Or  the  ulcerative  devastation  may  be 
chiefly  intra-buccal,  and  then  the  disease  may  burrow  into  the 
wall  of  the  cheek,  or  pass  into  the  floor  of  the  mouth,  and  dissect 
up  the  tongue  from  its  front  connection  to  the  floor  of  the  mouth. 
In  its  destructive  migration,  the  epithelioma  may  cross  the  roots  of 
vessels,  and,  opening  them,  cause  bleeding.  From  compression 
or  ulceration  of  the  gustatory  and  hypoglossal  nerves,  there  may 
be  loss  of  sensory  and  motor  function  of  one  side  of  the  tongue. 
The  ulcerated  breach  in  the  lip  permits  the  saliva  to  escape,  and, 
trickling  down  on  the  chin  and  falling  on  the  dress,  it  renders 
the  patient  intensely  repulsive  to  others,  and  quite  as  much  so  to 
himself.  The  ulcerated  ga'p  in  the  mouth  interferes  with  respira- 
tion and  the  taking  of  food. 

Thus,  as  seen,  the  epithelioma,  at  first  a  microscopically  small 


594  LABIAL    (iROWTHS. 

lesion,  may  widen  its  domain  of  destruction  until  it  ends  the  life 
of  its  victim;  in  its  career  it  is  akin  to  a  spark  of  tire  on  a  dress, 
which  a  touch  of  a  finger  may  extinguish,  hut  if  once  awakened 
into  a  flame,  a  hundred  hands  can  hardly  rescue  the  unfortunate 
one. 

A  remarkable  circumstance  in  connection  with  labial  epithe- 
lioma is  that,  during  its  incipient  period  of  development,  the 
slight  lesion  rarely  awakens  attention  on  the  part  of  the  })atient. 
The  trivial  breach  in  his  lip  arouses  no  suspicion  of  its  real 
nature;  and,  as  a  rule,  the  subject  is  only  awakened  to  his  true 
condition  when  the  disease  has  well  entrenched  itself  in  the  lip, 
and  has  produced  some  destruction  of  tissue. 

Causes. — The  epithelial  element  of  the  lip  is  launched  on  its 
aberrant  course  by  some  irritant  which  is  continued  in  action 
for  a  long  period;  such  irritation  may  be  caused  by  the  irritating 
action  of  the  smoker's  cigar  or  pipe-stem ;  or  the  nail,  tack  or 
other  object  which,  the  mechanic  daily  placing  in  his  mouth, 
presses  on  and  bruises  the  lip;  or  the  foul  content  of  an  uncleansed 
mouth  constantly  coming  in  contact  with  an  eroded  surface  of  the 
lip;  or  a  crack  or  cleft  in  the  border  of  the  lip  that  is  maintained 
in  a  raw  state  by  the  action  of  the  muscles  which  are  constantly 
moving  the  lips;  or,  finally,  any  occupation  in  which  the  mouth 
is  exposed  to  injury ;  of  which  a  rare  example  is  the  blowing  of 
food  into  the  beaks  of  fowls  which  are  subjected  to  forced  feeding 
to  hasten  their  fattening,  or  rather  fatty  degeneration.  An  erosion 
from  any  of  the  causes  enumerated,  often  finds  an  efficient  ally 
in  the  irritant  remedies  which  the  patient  applies  to  it ;  and 
a  further  efficient  ally  is  the  lingual  manipulation  with  which 
the  eroded  surface  is  continuously  tormented. 

To  what  extent  smoking  is  a  causal  agency  has  been  and 
remains  a  subject  of  contest  among  surgical  writers.  As  usual, 
those  who  smoke  are  partisans  for  their  favorite  pleasure,  and 
offer  numerous  plans  in  defense  of  its  harmlessness ;  and  an  argu- 
ment which  tliey  urge  is  that,  while  there  are  thousands  of 
smokers,  there  are  but  scattered  units  of  those  who  become  the 
subjects  of  labial  cancer.  To  this  their  opponents,  among  whom 
the  writer  is  included,  reply  that  labial  cancer  occurs  oftenest 
among;  men  who  smoke.  And  that  units  onlv  of  the  thou-sands 
of  smokers  become  affected  is  in  accord  with  the  deportment  of 
many  other  diseases;  though  many  are  exposed  to  attack,  yet 
but  a  few  become  the  subjects.  There  are  doubtless  constitutional 
conditions,  as  yet  undetermined,  which  dispose  to  the  develop- 


LABIAL    CANCER.  595 

merit  of  malignant  disease,  whether  in  the  form  of  epithelioma, 
sarcoma  or  carcinoma ;  in  those  with  such  predisponent  endow- 
ment, the  continued  irritation  of  the  stump  of  the  cigar  which 
often  remains  on  the  ground  after  its  trunk  has  been  consumed, 
becomes  the  final  causal  excitant  of  epithelioma.  The  rough 
stem  of  the  clay  pijje  does  the  work  more  surely,  since  it  has,  as 
co-workers,  unclean  mouth,  unclean  teeth  and  unclean  lips.  The 
heat  of  the  cigar  and  pipe  overheats  their  point  of  contact,  and 
the  drying  saliva  leaves  its  solid  content  on  the  lip;  some  irrita- 
tion must  thus  be  caused.  The  tobacco,  as  is  known,  contains 
nicotine,  a  most  active  principle,  whose  toxic  virulence  is  well 
known  to  the  pharmacologist.  In  the  methods  which  are  used 
to  prepare  the  tobacco  for  smoking  or  chewing,  ingredients  are 
compounded  with  it  which  are  said  to  set  free  ammonia  as  well 
as  the  alkaloid  nicotine,  and  thus  the  material  is  rendered  more 
acrid  than  it  is  in  its  natural  state.  Hence,  in  the  act  of  smok- 
ing, the  lip  is  irritated  by  heat  at  a  degree  which  almost  burns 
the  surface;  and. this  is  combined  with  the  action  of  nicotine, 
which  evidentl}^  impairs  and  lowers  the  vitality  of  the  part 
which  it  penetrates.  If  a  few  drops  of  nicotine,  introduced  into 
the  throat  of  a  bird,  causes  death,  as  has  been  found  to  be  the 
case,  it  certainly  must  have  a  depressing  effect  on  the  mucous 
surface  of  the  mouth.  As  this  action  may  be  exerted  within 
the  buccal  cavity,  the  smoker's  cancer  is  not  limited  to  his  lip, 
it  develops  quite  as  often  at  the  sides  of  the  base  of  the  tongue, 
and  on  the  pharyngeal  arch,  at  a  point  which  receives  the  impulse 
of  the  indrawn  smoke.  And  finally,  it  may  be  stated  that 
women,  rarely  smokers,  seldom  have  labial  cancer. 

Another  point,  strongl}^  in  favor  of  the  causal  agency  of  tobacco,  is 
the  greater  frequency  of  labial  epithelioma  since  the  use  of  tobacco 
has  become  more  prevalent;  this  disease  is  one  which  now  pre- 
sents itself  to  the  practicing  surgeon  oftener  than  any  other  form 
of  malignant  disease;  such  frequency  did  not  exist  a  century  ago, 
if  one  judge  of  the  matter  by  the  surgical  works  published  at  that 
time:  labial  cancer  was  not  spoken  of  as  a  frequent  occurrence 
by  Boyer,  Bell,  Heister,  Delpech,  Richter  and  Richerand;  but  the 
present  prevalence  of  the  disease  is  in  direct  ratio  to  the  popular 
use  6f  tobacco;  which  has  been  advanced  by  fashion  from  an 
occasional  luxury  to  that  of  a  necessity;  and  thus  promoted, 
tobacco  will  bafile  the  best  efforts  of  the  hygienist  who  seeks  to 
lessen  or  abolish  its  use.  The  "Counterblast  against  Tobacco" 
written  by  a  royal  hand,*  had  as  little  effect  in  checking  the  use 

*King  Jatnes  of  England. 


596  I.AIUAL    (JROWTHS. 

of  the  i)laiit  as  docs  the  knowledge  well  diiTusod  among  people 
that  cancer  may  thus  arise;  and  the  principle  here  obtains  that 
man  would  rather  add  to  the  sum  of  his  pleasures,  even  if  the 
added  material  must  be  taken  from  his  life.  In  fact,  the  altruis- 
tic virtue  "which  is  so  unseltisiily  illustrated  in  hygienic  medicine, 
and  which  sacrifices  itself  for  the  sake  of  others,  has  slight  extrin- 
sic recompense. 

Diagnosis. — The  labial  cancer  during  the  initial  period  of  its 
evolution  has  strong  analogy  with  the  primary  or  secondary 
lesion  of  syphilis.  Chancre  on  the  lip  must  originate  from  con- 
tact with  a  syphilitic  subject;  it  is  seen  oftener  in  the  female,  and 
quite  as  frequently  on  the  upper  as  on  the  lower  lip.  It  may  be 
multi}>le,  and  it  commences  often  on  tlie  outer  edge  of  the  border, 
and,  in  its  growth,  it  extends  towards  and  on  the  denn,  rather 
than  towards  the  mucous  membrane.  The  secondary  syphilitic 
manifestation  on  the  lips  is  oftencst  on  the  lower  lip.or  at  the  labial 
commissure;  and  in  the  latter  site,  it  involves  both  the  upper  and 
lower  lip.  This  eruption  is  commonly  in  the  form  of  the  mucous 
patch,  which  is  pearl-colored,  or  it  may  be  a  slight  ulceration  ; 
and  this  is  near  the  angle  of  the  mouth.  Labial  cancer,  in  any 
of  its  forms,  differs  in  appearance  from  the  primary  or  secondary 
manifestations  of  syphilis  above  mentioned:  namely,  tlie  flat 
form  is  slower  in  its  march  than  the  chancre  or  mucous  patch;  it 
is  surrounded  by  a  dark  crust,  and  a  horn-like  growth  may  spring 
from  it;  manifestations  unlike  anything  seen  in  the  course  of 
syphilis.  Tlie  i)apillary  epithelioma  is  drier  than  syphilitic  con- 
dyloma, and  has  more  contiguous  induration.  Tlie  nodular 
branches  which  the  epithelioma  projects  into  the  neighboring 
structures  are  multi})le,  while  the  gummy  development  is  usually 
single.  The  manifestations  of  syphilis  are  painless,  or  nearly  so: 
the  labial  cancer,  when  it  reaches  the  period  of  ulceration,  is 
painful.  Epithelioma  confines  its  devastations  to  the  structures 
of  the  face,  chin  and  front  of  the  neck;  syphilis  has  no  tendency 
to  local  isolation;  it  is  ubiquitous  in  its  secondary  site;  derm, 
muscle,  mucous  structure,  bone,  brain,  abdominal  viscus,  indis- 
criminately share  in  the  unenvied  privilege  of  giving  the  consti- 
tutional manifestations  of  syphilis  a  transient  if  not  a  permanent 
abiding  place.  Syphilis  is  capable  of  elimination,  and  cure  by 
the  use  of  mercury  and  iodine;  these  remedies  will  retard  epithe- 
lioma, as  the  author  has  verified  in  his  practice;  they  will,  how- 
ever, not  extinguish  and  cure  epithelial  cancer.  The  microscope 
mav  be  used  as  a  diagnostic  aid ;  a  small  section  placed  in  the 


LABIAL    CANCER.  597 

objective  field  will  discover  the  epithelial  constitution  of  the 
epithelioma;  the  cellular  elements  of  the  latter  will  sometimes 
be  found  in  the  interior  of  the  growth,  where  they  arise,  accord- 
ing to  Otto  Weber,  from  the  nuclear  elements  of  the  muscular 
components  of  the  lip;  such  a  cellular  structure  will  not  be  found 
in  tissue  wliich  has  arisen  from  syphilitic  action. 

Tubercular  disease  may  produce  induration,  swelling  and 
ulceration  similar  to  that  which  arises  from  labial  cancer.  Such 
tubercular  disease  appears  as  often  in  the  upper  as  in  the  lower 
lip.  Tuberculosis,  similar  to  syphilis,  does  not  confine  its  morbid 
action  to  so  limited  a  portion  of  the  organism  as  the  lip;  if  found 
there  it  will  be  found  elsewhere;  probably  in  a  gland,  in  the 
skin,  in  a  joint,  or  a  bone;  but  the  localized  site  of  epithelioma 
distinguishes  it  from  the  multifarious  site  of  syphilis.  The  sub- 
ject of  labial  cancer,  as  a  rule,  has  general  good  health ;  except 
]iis  lip,  he  is  sound  in  body;  the  reverse  usually  obtains  in 
secondary  syphilis,  or  in  tuberculosis. 

Prognosis. — The  inevitable  tendenc}^  and  undeviating  course 
of  labial  epithelioma  is  to  ever  enlarge  its  sphere  of  destructive 
action;  to  spread  from  the  lip  to  parts  near  by;  and  by  con- 
tinued ulceration  and  ichorous  suppuration  to  undermine  the 
patient's  vital  forces,  and  finally  destroy  his  life.  In  the  early 
stage,  the  disease  is  easily  curable  by  proper  treatment;  if 
allowed  to  reach  the  adjacent  glands,  it  is  incurable.  The  poor 
and  penniless  are  oftener  cured  than  the  rich;  since  the  former 
are  forced  to  depend  on  surgical  aid  which  is  furnished  him  by 
the  city  or  State;  while  the  rich,  having  exhausted  their  intelli- 
gence in  the  acquisition  and  maintenance  of  their  fortunes,  seem 
to  have  none  left  for  their  guidance  in  medical  matters.  At 
least,  this  has  been  the  personal  experience  of  the  writer.  Dives 
is  careful  to  choose  a  skilled  engineer  to  construct  an  irrigating 
canal,  or  pioneer  the  route  for  a  proposed  railroad;  he  would 
scout  the  overtures  of  one  who,  with  no  knowledge  of  painting, 
would  offer  to  paint  his  portrait:  he  would  look  into  and  investi- 
gate the  qualifications  of  a  surgeon  for  his  domestic  animals; 
and  yet  such  a  one  often  submits  his  own  disordered  body  for 
treatment  to  one  who  is  ignorant  of  both  Anatomy  and  Pathol- 
ogy. Often  the  author  has  been  consulted  by  a  patient  whose 
face  had  been  laid  waste  by  cancerous  disease,  which,  at  first  of 
minimum  form,  had  been  cultivated  to  its  great  dimensions  by 
the  industrious  hand  of  the  ignorant  charlatan;  and  through 
ignorance  or  misguidance,  such  patient,  once  easily  curable,  was 
doomed  to  a  cruel  death. 


508  LAIUAL    (JHONVTIIS. 

Statistics  of  Labial  Cancer. — In  1887  Maiweg  published  observa- 
tions made  at  the  surgical  clinic  of  Bonn  on  labial  cancer. 
These  observations  embraced  four  hundred  cases,  of  which  three 
hun(h-ed  and  sixty-six  were  men,  and  thirty-four  women;  that 
is,  there  were  eiglit  and  live-tenths  })er  cent  of  females.  In  the 
entire  number  there  were  twenty-two  in  which  the  disease  was  on 
the  upper  lip,  and  one-half  of  these  were  females.  In  respect  to 
age,  the  most  of  the  patients  were  between  fifty-six  and  sixty-five 
years.  After  seventy-live  years,  the  disease  is  rarely  observed. 
The  average  time  which  the  disease  had  existed  when  medical 
aid  was  sought  was  two  years.  Of  one  hundred  and  eighty-two 
persons  operated  on,  one  hundred  and  twenty-five  remained  free 
from  the  disease;  that  is,  the  disease  was  cured  in  two-thirds  of 
the  cases. 

Worner  of  Tubingen  has  observed  three  hundred  and  five 
cases  of  cancer  of  the  lip.  Of  these  cases  ten  ])er  cent  were 
women;  and  three  were  seen  who  were  under  thirty  years  of  age. 
The  subjects  were  nearly  all  of  the  laboring  class.  In  sixteen  of 
the  three  hundred  and  five  cases,  the  upper  lip  was  the  site  of 
the  disease.  Of  two  hundred  and  seventy-seven  persons  operated 
on,  one  hundred  and  six  remained  well  during  a  period  of  three 
years  in  which  they  were  observed.  The  mortality  was  five  and 
seventy-seven-hundredths  per  cent,  and  was  from  secondary  com- 
plication of  the  lungs.  Melzer,  in  I80O,  in  a  report  of  patients 
received  at  the  hospital  of  Laibach,  states  that  every  sixtieth  one 
was  a  case  of  labial  cancer;  he  attributes  the  frequency  of  the 
disease  to  the  use  of  a  pipe  whicli  was  covered  with  copper. 

From  all  the  publications  accessible  to  AVorner,  there  were 
collected  eight  hundred  and  sixty-six  cases  of  labial  cancer,  of 
which  ninety  and  four-tenths  per  cent  were  in  males.  The 
upper  lip  was  the  site  in  five  and  six-tenths  per  cent  of  the 
cases.  Of  those  having  the  disease  in  the  upper  lip,  the  greater 
number  were  females.  The  average  mortalitv  from  the  opera- 
tion was  seven  percent;  and  the  recoveries  obtained  by  operating 
were  twenty -eight  per  cent. 

The  percentage  of  recoveries  as  here  reported  is  strikingh' 
small,  and  can  only  be  accounted  for  on  the  ground  that  the 
cases  were  well  advanced  when  the  operation  was  done;  or  else 
the  work  was  imperfectly  done;  probabh^  both  of  these  agencies 
.shared  in  the  causation;  since,  from  the  writer's  experience, 
which  has  not  Ijeen  limited  in  this  section  of  operative  surgery, 
it  is  a  rare  event  that  the  patient  is  not  cured,  if  extirpation  be 


LABIAL    CAXCER.  o9y 

thoroughly  done  at  an  early  period.  The  patient,  if  seen  and 
operated  on  early,  can  be  assured  of  permanent  relief  from  his 
affliction. 

Treatment. — The  patient  requires  two  things  from  his  surgeon: 
viz.,  that  the  diseased  portion  of  his  lip  be  removed,  and  that  the 
continuity  of  the  lip  be  so  preserved,  that  it  will,  in  some  measure, 
act  the  part  of  a  retaining  wall,  which  is  an  important  function 
of  the  normal  lip.  As  a  considerable  portion  of  the  lip  is 
sometimes  sacrificed,  a  third  operative  act  is  often  required, 
viz.,  restoration  of  this  retaining  wall,  by  the  procedure  of 
cheiloplasty. 

Inasmuch  as  labial  cancer  is  especially  a  disease  of  the  lower 
lip,  the  latter  will  usually  be  the  site  of  the  operative  work.  The 
removal  may  be  done  by  cauterization,  potential  or  actual,  or  by 
section  made  with  knife  or  scissors. 

The  proximate  relation  of  the  lip  to  the  buccal  cavity,  renders 
it  difficult,  if  not  hazardous,  to  apply  a  destructive  escharotic  to 
the  lip;  and  should  cauterization  be  resorted  to,  the  thermal 
method  would  be  the  preferable  one;  but  the  open  breach  which 
must  then  remain,  even  though  this  be  temporary,  is  a  strong 
objection  against  this  mode  of  treatment.  Excision,  then,  becomes 
the  method  which  is  almost  universally  adopted,  since  the  scissors 
or  scalpel  do  their  work  instantaneously;  and  the  incision  made 
enables  one  to  inspect  the  divided  tissue;  and  if  all  the  affected 
structure  has  not  been  removed,  one  can  remove  another  seg- 
ment. The  incisions  may  be  so  made  as  to  as.sist  in  the 
concluding  operative  act,  viz.,  that  of  closing  the  breach  made. 

Excision,  as  stated,  may  be  done  with  scissors  or  scalpel ;  as  a 
rule,  strong  scissors,  with  curved  blades,  and  sharp  at  the  points, 
do  the  work  most  easily.  An  aneesthetic  should  be  used,  if  the 
patient  desires  it;  the  writer,  in  many  cases,  has  done  the  work, 
in  sesthesia,  the  patient  choosing  to  show  his  powers  of  endurance 
without  further  aid  than  his  innate  courage.  Instead  of  a 
general  anesthetic,  sensation  might  be  suspended  locally  by 
injecting  into  the  lip  a  few  drops  of  a  four-per-cent  solution  of 
muriate  of  cocaine.  By  this  local  ansesthesia,  vomiting  will  be 
avoided,  and  this  risk  of  disturbing  the  work  will  be  shunned; 
but  from  the  writer's  observation  it  is  rare  that  the  injected 
cocaine  wholly  annuls  sensation ;  the  division  of  the  cocainized 
structure  causes  pain. 

Only  a  small  operation  is  required  where  there  is  a  slight 
erosion  of  the  mucous  border  of  tlie  lip,  and  the  removal  can 


OOO  J.AIUAI,    (JKOWTIIS. 

here  be  done  by  means  of  a  su[)erHcial  wedge-shaped  excision, 
in  which  the  cutting  is  done  antero-posteriorly  or  laterally,  as 
may  be  best  suited  to  remove  tlie  affected  part.  The  gap  made 
must  be  closed  by  one  or  more  sutures,  and  the  surface  then 
covered  witli  a  coating  of  the  tincture  of  benzoin. 

If  the  disea.se  involves  a  larger  portion  of  the  border  of  the 
lip,  and  has  perforated  to  some  depth:  for  example,  if  the  erosion 
be  a  half  inch  or  more  on  the  labial  edge,  then  a  larger  excision 
must  be  done;  and  this  should  be  of  a  triangular  or  quadrangular 
form;  the  more  usual  one  is  tlie  triangular  one,  in  which  a 
wedge-shaped  portion  of  structure  is  removed.  Whether  knife 
or  scissors  be  used,  the  incision  should  bo  at  least  a  half  inch 
beyond  the  affected  tissue,  within  the  sound  structure.  And  to 
be  sure  that  this  has  been  done,  the  excised  portion  should  be 
carefully  examined;  and  then,  if  it  be  suspected  that  enough 
has  not  been  excised,  more  structure  should  be  removed.  This 
cuneiform,  mode  of  excision  is  a  favorite  with  the  operating  sur- 
geon, since  it  can  be  rapidly  done,  and  the  gap  made  can  be 
closed  by  direct  apposition;  if  the  gap  is  not  great,  the  sides  can 
be  brought  together  and  retained  so  by  suture.  There  is,  how- 
ever, the  serious  objection  that  structure  is  unneces.sarily  sacri- 
ficed in  the  lower  part  of  the  triangle;  and  further,  the  narrowing 
of  the  excision  as  it  passes  from  the  labial  border  involves  the 
ri.sk  of  leaving  behind  germinal  elements  of  the  epithelioma; 
and  this  will  be  greater  the  shorter  the  wedge  is.  A  preferable 
cut,  then,  is  one  of  quadrangular  form,  of  which  the  vertical 
sides,  commencing  a  half  inch  outside  of  the  affected  j)art,  shall 
extend  from  one  to  two  inches  beyond  the  labial  border;  these 
vertical  incisions  are  to  be  united  by  a  horizontal  one.  To 
restrain  the  bleeding,  which  follows  either  the  triangular  or  quad- 
rangular excision,  compression  of  the  coronary  arteries  should  be 
made,  either  with  clasp  forceps  or  with  the  fingers  of  an  assist- 
ant; the  former  are  less  in  the  way;  the  latter  are  more  apt  to  be 
at  hand. 

The  quadrangular  breach  thus  made  in  the  lip  may  be  closed 
by  one  of  several  cheiloplastic  procedures.  ISince  the  object  of 
tiiese  operations  is  to  prevent  deformity,  the  replacing  material 
should  be  selected  where  its  removal  will  cause  the  least  possible 
scarring;  and  to  accomplish  this,  the  attempt  has  been  made  to 
restore  the  removed  structure  by  material  taken  from  the  arm. 
Brachial  restoring  material  was  used  by  Graefe,  Berg,  Schuh, 
Wutzer,  and  others;  the  result  has  only  been  partially  satisfac- 


LABIAL    CANCER.  601 

tory;  in  Wutzer's  case  alone  the  attempt  was  in  some  degree 
satisfactory.  Such  work  is  unsatisfactory  in  the  color  of  the 
derm  which  is  transplanted,  and  in  the  shriveled  or  folded  form 
which  the  transplanted  structure  assumes.  In  Schuh's  case  the 
brachial  flap  rolled  up  into  an  ill-shaped  mass;  in  Wutzer's 
operation  the  material  was  taken  from  the  outside  of  the  fore- 
arm above  the  wrist;  and  this  had  the  fa-ult  of  not  being  of  the 
same  color  as  that  of  the  adjoining  face.  For  these  reasons,  the 
operator  should  select  material  for  restoration  from  the  chin  or 
the  side  of  the  face,  and  as  that  from  the  chin  leaves  a  less  con- 
spicuous mark,  one  should  choose  there,  if  possible,  material  for 
restoration. 

In  case  cuneiform  excision  be  done  in  the  lower  lip,  if  the 
portion  removed  does  not  exceed  an  inch  in  breadth,  then  direct 
closure  can  be  done;  the  oral  opening  will  then  be  rendered 
smaller;  yet,  in  time,  this  condition  is  lessened  through  the 
normal  extensibility  of  the  labial  structure;  nevertheless,  the 
narrowed  mouth  is  a  source  of  inconvenience,  and  where  the 
mouth  will  be  rendered  very  small  it  is  well  to  enlarge  it.  This 
widening  can  be  done  by  a  horizontal  incision  carried  laterally 
from  the  labial  commissure  that  is  nearest  the  excision;  and  if 
the  excision  occupy  the  median  portion  of  the  lip,  then  a  hori- 
zontal incision  should  be  made  at  each  angle  of  the  mouth.  To 
prevent  these  lateral  cuts  from  closing,  on  the  lower  margin  of 
each  the  mucous  membrane  and  derm  should  be  united  by 
sutures.  To  obtain  this  muco-dermal  union,  in  making  the 
horizontal  incision,  a  small  mucous  flap  can  be  constructed  on 
the  inside,  which  can  afterwards  be  folded  outwards  over  the  raw 
border;  or  a  horizontal  cuneiform  excision  from  the  cut  border 
would  permit  of  a  similar  muco-dermal  closure.  It  suffices  to 
make  this  closure  in  either  the  upper  or  the  lower  margin. 
Where  commissural  elongation  is  made,  the  extension  should 
equal  the  breadth  of  the  excised  portion. 

In  directly  closing  the  wound  in  the  lower  lip,  either  with  or 
without  commissural  elongation,  there  will  be  formed  a  fold  on 
the  upper  lip ;  also  the  margin  of  the  upper  lip  will  project 
beyond  that  of  the  lower  lip;  or,  if  the  exceptional  case  occur 
that  the  excision  is  done  from  the  upper  lip,  then  an  analogous 
folding  or  puckering  will  be  formed  in  the  lower  lip.  To  correct 
this,  the  plan  of  Burow  may  be  followed,  by  which  the  surplus 
fold  is  sacrificed  by  the  excision  of  a  triangle.  Instead  of  losing 
this  tissue,  the  author  would  endeavor  to  save  it  by  forming  a 
39 


002 


I.AIUAL    (JKOWTIIS. 


pedicled  flap  from  the  sur})lus  fukl,  and  then,  having  incised  the 
op])osite  border,  wlietlier  this  be  tlie  U2)per  or  lower  lip,  circum- 
duct the  Hap,  and  insert  and  fix  this  by  suture  in  the  gap  formed 
for  it.  Another  plan,  advised  by  Weber,  is  to  elongate  the  com- 
missure by  an  incision  curving  downwards  towards  the  margin 
of  the  lower  jaw,  if  the  disease  be  on  the  inferior  lip.  When  this 
incision  is  made,  the  lower  portion  of  it  may  be  sutured  in  such 
a  way  as  to  remove  much  of  the  fold;  and  this  is  done  by  draw- 
ing downwards  the  outer  border,  and  sliding  upwards  the  inner 
border  of  the  excision. 

The  cheiloi^lastic  restoration  is  often  done  by  means  of  ped- 
icled fla])s  taken  from  the  adjacent  surface.  If  the  breach  to  be 
filled  be  a  quadrangular  one  in  the  lower  lip,  then  the  plan  of 
Sedillot  may  be  resorted  to,  viz.:  lateral  flaps  with  upward  base 
near  the  angles  of  the  mouth  are  uplifted  and  made  to  fill  the 
breach.     This  plan  is  shown  in  Figures  85  and  80.     Or  a  plan 


Figure  85.  Showing  Sedillot's 
plan  of  forming  flaps  for  closure  of 
quadrangular  breach  in  the  lower 
lip. 


Figure  86.  In  which  is  shown  the 
result  of  closure  by  Sedillot's  method. 
(From  Emmert.) 


the  reverse  of  this  has  been  resorted  to  by  Bruns;  here  the  flaps 
have  pedicles  below,  and  their  free  sides  are  formed  from  the 
cheeks.  Tlie  plan  of  Sedillot  is  the  preferable  one,  since  the  scars 
formed  will  be  on  the  lower  part  of  the  face,  where  they  are  more 
readily  concealed. 

The  replacing  flap,  wlien  it  is  brought  into  place  by  circum- 
duction, can  be  given  a  form  which  will  correspond  to  that  of  the 
breach  made  in  the  excision  of  the  epithelioma ;  thus,  it  may 
have  a  quadrangular,  triangular,   trapezoidal,  ovoidal,  or  even 


LABIAL    CANCER.  603 

some  nameless  shape,  provided  it  will  thus  fill  the  breach. 
And  in  this  work  the  operator  must  bear  in  mind  the  retractility 
of  the  uplifted  flap;  an  allowance  should  be  made  for  a  diminu- 
tion of  its  surface;  and  this,  when  the  material  is  abandoned, 
should  be  equal  to  one-third  of  the  replacing  material. 

The  Celsian  procedure  is,  sometimes,  conveniently  used  to 
close  a  quadrangular  breach  made  in  the  lip;  this  consists  in 
elongating  horizontally  the  basial  cut,  or  that  nearest  the  attach- 
ment of  tlie  lip;  thus  lateral  flaps  are  formed  which  can  be  jux- 
taposed by  lateral  sliding. 

Should  the  disease  involve  the  angle  of  the  mouth,  then  there 
arises  the  problem  of  canthoplasty,  which  is  a  difficult  one  to 
solve;  one  solution  of  it  is  the  method  pursued  by  Mackenzie,  in 
1851.  This  consists  in  forming  a  flap  with  a  curved  border  on 
the  side  of  the  chin;  then  split  this  horizontally,  so  that  one 
portion  can  form  the  lower,  and  the  other  the  upper  border  of  the 
commissure.  To  prevent  this  angle  from  closing,  a  portion  of 
mucous  membrane  should  be  dissected  up,  wherever  it  is  most 
accessible,  and  sutured  in  the  angular  gap. 

Instead  of  the  plan  described,  an  angle-bearing  flap  might  be 
uplifted  from  the  side  of  the  face,  and  so  turned  into  the  breach 
that  the  angle  contained  in  it  would  occupy  the  site  of  the 
intended  commissure.  In  this  way  a  flap  taken  from  the  fore- 
arm might  be  modeled  and  utilized,  if  material  adjacent  were 
wanting. 

In  case  the  entire  lower  lip  is  removed  by  a  crescentic  incis- 
ion, Weber  advises  to  close  the  breach  by  means  of  two  semi- 
crescentic  flaps  formed  below  the  breaches.  One  of  these  flaps  is 
to  be  uplifted  and  drawn  across,  so  as  to  form  the  upper  part  of 
a  new-formed  lip  ;  next,  the  remaining  flap  is  to  be  elevated  and 
so  fixed  as  to  support  the  upper  flap.  These  flaps  are  to  be 
retained  in  position  by  metallic  sutures.  After  closure  has  been 
done  in  this  manner,  there  will  remain  an  open  space  on  the 
chin. 

In  case  there  exist  alternate  sections  of  sound  and  diseased 
tissue,  AVeber  removes  the  affected  portion  by  triangular  excisions, 
the  bases  of  which  open  towards  the  mouth.  By  this  plan  of 
compound  triangular  excisions,  a  destroyed  commissure  can  in 
some  measure  be  restored ;  and  it  has  another  advantage,  that  it 
shuns  the  needless  sacrifice  of  unaffected  structure. 

The  patient  may  present  himself  for  treatment  after  the  disease 
has  extended  beyond  the  labial  region;  and  by  such  extension 


604  LABIAL   GROWTHS. 

the  disease  may  implicate  the  adjacent  buccal  wall,  and  even  the 
osseous  structure  of  the  lower  or  upper  jaw;  and  simultaneously 
with  this,  the  lymphatic  glands  in  the  inferior  maxillary  arch, 
and  the  upper  part  of  the  neck  may  be  affected.  According  to 
the  writer's  observation,  if  the  epithelioma  has  attacked  the 
maxilla  and  appeared  in  the  glands,  an  operation  will  be  followed 
by  recurrence  at  no  distant  period. 

If  the  disease  involves  the  cheek,  the  affected  part  should  be 
excised  by  a  circumscribing  cut,  and  the  opening  i:)lastically 
closed.  Special  care  sliould  be  taken  to  avoid  a  salivary  fistula 
should  the  Stenonian  duct  be  involved;  and  this  may  be  done  by 
dissecting  up  the  posterior  portion  of  the  severed  duct  and  turn- 
ing this  directly  into  the  buccal  cavit3^  In  this  wise,  the  author 
has  successfully  operated  in  a  case  in  which  the  terminal  part  of 
the  duct  was  diseased. 

If  the  lower  jaw  is  involved,  and  the  malignant  disease  has 
penetrated  to  its  central  canal,  then  a  portion  of  the  body  of  the 
jaw  should  be  exsected  ;  and  this  is  best  done  by  a  small  saw  by 
which  the  opposite  sawn  faces  can  be  so  shaped  and  inclined  that 
tliey  can  bo  apposed  and  united  by  metallic  suture.  In  case  the 
bone  be  slightly  affected  on  its  surface,  the  entire  thickness 
need  not  be  removed;  still,  the  disease  may  have  penetrated 
beyond  the  surface,  so  that  superficial  removal  of  surface  will 
soon  be  followed  by  reappearance  of  tlie  disease;  in  all  such  cases 
the  exsection  should  reach  well  into  the  bone:  at  least  through 
one-lialf  its  thickness. 

At  some  period,  early  or  remote,  tlie  disease  passes  beyond  its 
primary  marginal  site  and  commences  a  migration  into  structures 
contiguous;  that  is,  the  neoplastic  invader  makes  provision  for  a 
successor  in  a  new  quarter,  after  it  has  consumed  the  structures 
which  it  first  attacked;  and  this  secondary  site  is  the  structure 
within  the  inferior  maxillary  arch  and  the  anterior  structures  of 
the  neck;  and  the  first  points  of  metastatic  appearance  there  are 
the  lymphatic  glands  which  lie  near  the  submaxillary  gland. 
The  lymphatic  vessels  which  convey  the  germinal  elements  of  the 
epithelioma  seem  to  remain  exempt  from  infection.  The  infected 
glands  are  connnonly  on  the  same  side  as  the  affected  point  of 
the  lip,  and  they  are  tlie  ones  wliicli  become  secondarily  attacked 
when  the  epithelioma  appears  at  the  root  of  the  tongue  or  in  the 
arch  of  the  pharynx.  An  exception  to  this  rule  of  reappearance 
was  seen  by  the  author  in  one  case  in  which  the  glandular  infec- 
tion occurred  on  the  oi)posite  side  of  the  neck. 


LABIAL    CANCER.  605 

The  proximate  relation  of  the  lymphatic  giands  to  tne  sub- 
maxillary gland  exposes  the  latter  to  implication,  so  that  finally 
the  submaxillary  gland  becomes  also  infected;  and  without  much 
swelling,  tlie  submaxillary  gland  finally  ulcerates  and  a  portion 
of  its  structure  is  destroyed. 

When  labial  epithelioma  has  advanced  to  the  stage  of  glandu- 
lar infection,  in  no  instance  has  the  writer  seen  the  case  perma- 
nently cured,  even  though  the  affected  lip  be  radically  excised, 
and  the  glands  carefully  removed;  recurrence  of  the  malady  has 
been  the  invariable  fate  of  the  victim.  However,  in  such  cases, 
the  operation  is  advisable,  since  the  wound  made  will  recover, 
and  the  patient  is  cheered  with  the  illusive  hope  that  he  is  really 
cured;  an  illusion  which  is  sometimes  unv/isely  broken  by  the 
surgeon  revealing  to  the  patient  his  own  fears.  The  kindness  of 
the  physician  is  nobly  and  laudably  exerted  when  he  promotes 
the  expectation  of  relief;  he  who  would  do  otherwise  is  a 
stranger  to  those  sentiments  of  humanity  which  belong  to  the 
morality  of  medicine. 

In  case  the  epithelioma  has  infiltrated  the  structures  on  the 
chin,  and  the  upper  part  of  the  neck,  and  the  infected  glands 
have  suppurated,  the  affected  field  of  nodulated  surface  presents 
a  number  of  crateriform  openings  through  which  flocculent,  case- 
ous, fetid  detritus  is  discharged;  then  a  radical  removal  of  the 
disease  is  impossible,  and  any  oj)erative  procedure  must  be  limited 
to  an  essay  to  remove  the  diseased  structure,  and  thus  diminish 
the  foul  discharge.  This  work  is  best  done  by  the  use  of  the 
curette,  care  being  taken  to  avoid  the  blood-vessels.  And  for 
dressing  a  disinfectant  may  be  applied;  for  example,  a  chlori- 
nated solution,  or  one  prepared  from  the  permanganate  of  potash, 
may  be  used.  Such  a  one  is  Condy's  solution  containing  two 
drachms  of  the  permanganate  of  potassium  to  two  ounces  of  water, 
which  may  be  used  in  this  strength,  or  diluted  with  an  equal 
quantity  of  water. 

In  the  advanced  stage  of  the  disease  in  which  the  use  of  the 
knife  would  be  a  fruitless  adventure,  the  writer  has  endeavored 
to  retard  the  progress  of  the  disease  by  the  parenchymatous  use 
of  remedies;  and  agents,  which  his  experience  sanctions  the 
emiDloyment  of,  are  Fowler's  solution  of  arsenic,  the  tincture  of 
iodine,  the  fluid  extract  of  ergot,  and  the  solution  of  the  muriate 
of  lime.  Of  the  agents  here  enumerated,  the  arsenical  solution 
seems  to  have  acted  the  best.  Should  further  opportunity  offer 
for  this  work,  he  would  try  the  spirit  of  turpentine,  which  is  one 


GOG  LABIAL    (iKOVVTHS. 

of  the  most  efficient  germicides  known.  These  remedies  are 
introduced  by  means  of  tlie  common  hypodermic  syringe.  To 
do  this  work  begin  with  the  tincture  of  iodine,  of  which  two  or 
three  drops  may  be  injected  at  six  or  eight  points;  some  of  these 
points  may  be  in  the  diseased  structure,  while  others  may  be  in 
the  parts  which  bound  the  growth.  The  amount  injected  shouhl 
not  be  enough  to  cause  death  and  sloughing  of  tissue.  In  this 
procedure  the  tissues  acquire  tolerance  to  the  agent  injected,  so 
that  after  a  day  or  two,  tlie  injection  may  be  done  at  a  greater 
number  of  points.  After  the  iodine  has  been  used  for  a  week, 
tlie  solution  of  muriated  lime  may  be  used  similarly,  and  in  the 
same  amount  as  the  tincture  of  iodine  was  used.  In  the  third 
week,  the  arsenal  solution  may  be  similarly  injected;  and  in  the 
fourth  week  the  spirit  of  turpentine  may  be  employed.  And 
should  a  fifth  agent  be  tried,  the  writer  would  advise  the  trial  of 
stramonium,  which  as  a  topical  application  has  retarded  the 
progress  of  malignant  growths.  For  interstitial  injection  the 
tincture  of  stramonium  may  be  used.  As  here  delineated,  five 
agents  are  to  be  injected  successively,  each  one  week,  and  then 
the  cycle  to  be  resumed  and  repeated  in  the  same  order.  . 

The  writer  anticipates  more  than  mere  retardation  of  the  epi- 
thelioma by  this  plan;  it  is  very  probable  that  the  trial  of  a 
large  number  of  medicinal  agents  would  end  in  tlie  discovery  of 
one  wliich  would  act  curatively.  And  the  writer  is  pleased  to 
note  that  essays  in  this  work  are  just  now  being  made  with 
agents  very  remote  from  those  hitherto  known  to  the  pharmacist, 
viz.,  with  antitoxin  lymphs;  and  among  those  the  germ  of 
erysipelas,  as  if  to  atone  for  the  many  lives  it  has  destroyed,  is 
now  lending  its  virus  for  the  cure  of  the  malignant  neoplasm. 
Such  experimental  work  carried  out  in  the  cautious  manner  here 
indicated,  has  a  promising  and  inviting  future.  As  Kepler 
charted  out  the  heavens  with  tentative  diagrams  with  untiring 
patience  before  he  hit  on  those  which  proved  his  three  immortal 
laws,  so  the  physician  must  patiently  work  who  would  find  the 
agent  to  vanquish  and  eliminate  malignant  disease;  but  once 
discovered,  the  blessing  will  be  as  enduring  as  the  laws  of 
Kepler. 


CHAPTER  XVIII. 


TOXGUE. 


Surgical  Anatomy. — The  tongue  completely  fills  the  buccal 
cavity  when  the  lower  jaw  is  fully  uplifted,  and  the  mouth  is  closed ; 
this  assertion  made  by  a  noted  anatomist  is  not  verified  by  the 
inspection  of  the  buccal  cavity  of  one  whose  absent  teeth  permit 
of  its  exploration ;  and  this  extensive  occupation  of  the  cavity 
when  the  mouth  is  shut,  contrasts  with  the  open  space  which  is 
present  when  the  mouth  is  widely  opened. 

The  striking  characteristic  of  the  tongue  is  its  great  mobility; 
even  the  hyoid  bone  and  the  portion  of  the  floor  of  the  mouth  to 
which  the  tongue  is  fastened,  are  mobile  and  permit  the  tongue 
in  its  movements  to  shift  its  points  of  attachment;  this  occurs 
when  the  tongue  is  well  protruded,  or  drawn  forwards.  This 
lack  of  fixation  permits  the  tongue  to  recede  backwards,  and  so 
occupy  and  occlude  the  pharynx  as  to  obstruct  the  entrance  of 
air  into  the  larynx.  Beneath  the  anterior  portion  of  the  tongue 
is  a  fold  of  mucous  membrane  named  the  frsenum  lingua, 
which,  rising  from  the  floor  of  the  mouth,  is  attached  to  the  free 
portion  of  the  tongue  in  the  median  line.  This  bridle-like  fold 
limits  the  forward  movement  of  the  tongue. 

The  marvelous  mobility  of  the  tongue  arises  from  the  dis- 
position of  the  muscles;  these  are  disposed  in  vertical,  longi- 
tudinal and  transverse  direction;  the  genio-hyo-glossi  and  the 
hyoglossi  act  in  a  vertical  plane;  the  linguales  act  in  the  antero- 
posterior direction,  and  the  transversus  lingua  muscle  acts 
transversely. 

The  lingual  structure  similar  to  that  of  the  heart,  contains 
but  little  fibrous  tissue;  such  tissue  is  found  principally  in  a 
central  septum  which,  placed  antero-posteriorly,  vertically  sepa- 
rates the  muscularity  of  the  tongue  into  two  lateral  portions; 
and  from  this  fibrous  portion  arises  the  transverse  lingual  muscle. 
This  septum  becomes  much  thinner  as  it  proceeds  forwards,  and 
finally  vanishes  in  the  anterior  part  of  the  tongue.     There  exists 

(607) 


608  TONGUE. 

a  small  amount  of  interstitial  adipose  tissue  in  the  posterior  half 
of  the  tongue. 

The  tongue  is  the  special  organ  of  the  gustatory  sense;  and 
this  is  seated  in  the  superior  surface,  in  papillse  of  conical,  filiform, 
fungiform  and  calyciform  or  circuravallated  form.  The  filiform 
and  conical  papilla?  are  most  numerous  on  the  middle  portion  of 
the  dorsum ;  the  fungiform  are  most  numerous  at  the  point  and 
on  the  dorsum. 

The  most  important  to  the  surgeon  of  the  lingual  papillfe  are 
the  circumvallated  species,  which  lie  on  the  hase  of  the  tongue  in 
two  lines,  which  converging,  meet  behind,  and  form  an  angle 
which  opens  forwards.  The  papilla  at  the  point  of  this  angle 
lies  in  a  depression  which  is  named  the  foramen  coecum.  The 
circumvallated  papillae  are  hidden  from  view  so  that  their  pos- 
sessor rarely  sees  them,  unless  he  makes  some  exploratory  search 
into  his  throat;  and  on  seeing  them  he  is  frequently  alarmed, 
and,  thinking  that  he  has  some  growth  appearing,  he  presents  his 
throat  and  fears  to  his  phj'sician;  and  from  the  latter  he  should 
learn  that  these  eminences  are  the  most  important  instruments 
of  taste,  and  are  potent  factors  in  the  pleasures  of  the  table. 

The  non-papillary  portion  is  the  site  of  numerous  small 
glands  which  empt}^  their  excretion  into  small  follicle-like 
depressions.  Glandules,  deemed  cognate  to  the  sublingual  gland, 
lie  along  the  border  of  the  tongue.  On  each  side,  within  the 
structure  of  the  stylo-glossi  muscles,  lie  glandular  masses,  discov- 
ered by  E.  H.  Weber;  and  on  the  inferior  surface  near  the  point, 
lie  two  glands,  described  by  Blandin,  and  of  which  the  excretory 
ducts  open  on  the  fraenum.  The  posterior  fourth  of  the  tongue, 
which  lies  between  the  calyciform  papillae  and  the  epiglottis,  has 
been  found  by  Billroth  and  Kolliker  to  be  the  site  of  a  lymphoid 
tissue.     In  this  ti.ssue  glands  and  follicles  are  found. 

The  lingual  arteries  anastomose  in  the  anterior  portion  of  the 
tongue;  hence  the  oozing  of  blood,  which  occurs  in  section  or 
removal  of  one  side  of  the  tongue,  though  the  corresponding 
artery  has  been  ligated.  Besides  the  lingual,  the  sublingual,  a 
derivative  of  the  facial  artery,  furnishes  blood  to  the  tongue; 
thence  some  bleeding  arises  in  removal  of  the  tongue,  though 
both  lioguals  have  been  previou.sly  tied.  This  bleeding,  as  the 
writer  has  witnessed,  is  slight,  and  is  readily  controlled. 

The  lymph-vessels  have  been  studied  by  Teichmann,  who 
finds  them  numerous  and  disposed  in  close  net-form,  in  front  of 
the  circumvallated  glands,  and  these  lymphatics  are  more  super- 


DEFORMITIES.  C09 

ficial  than  the  veins.  As  one  passes  backwards,  the  meshes 
become  wider,  and  the  vessels  of  greater  size.  The  lymphatics 
situated  in  the  posterior  portion  of  the  tongue  and  on  its  sides 
converge  to  glands  which  lie  in  front  of  the  internal  jugular  vein ; 
those  from  the  dorsal  face  of  the  tongue  pass  to  glands  near  the 
submaxillary  gland.  And,  thirdly,  the  lymphatics  from  the 
anterior  part  of  the  tongue  pass  to  glands  lying  on  the  thyroid 
gland.  Cancer  seated  in  the  posterior  part,  the  dorsal  or  superior 
face,  or  in  the  anterior  part  of  the  tongue,  will  reappear  in  one  of 
the  corresponding  glandular  sites  here  mentioned. 

According  to  Cruveilheir,  the  tongue  of  the  embryo  begins 
to  appear  in  the  median  line  of  the  floor  of  the  mouth,  in  the 
seventh  week,  as  a  minute  bud  or  tubercle. 

Deformities. — The  tongue  is  the  subject  of  numerous  deviations 
from  normal  form,  which  may  be  congenital  or  acquired ;  they  are 
commonly  congenital,  in  which,  from  some  error  in  development, 
the  part  wanders  from  its  typical  conformation ;  for  example,  in 
the  new-born,'the  tongue  may  be  wanting;  it  may  be  bifid  or  it 
may  be  too  large;  and  when  too  large  it  may  be  so  voluminous  as 
to  be  protruded  from  the  mouth.  The  mobility  of  the  tongue  may 
be  hampered  by  adhesions  which  may  be  above,  below  or  lateral. 

Complete  absence  of  the  tongue  has  not  been  seen;  such 
absence  has  been  merely  partial,  that  is,  there  existed  a  stump 
adherent  to  the  floor  of  the  mouth,  and  this  may  consist  of  two 
or  more  parts.  Loss  of  the  greater  part  of  the  tongue  has 
arisen  from  accident;  also,  from  the  surgeon's  knife.  Such  rudi- 
mentary tongue,  contrary  to  rational  supposition,  serves  fairly 
well  as  the  instrument  of  speech;  this  ceases  to  be  surprising 
when  an  analysis  is  made  of  the  mechanism  of  articulate  speech: 
since  such  examination  discovers  that,  of  the  elementary  sounds 
which  are  formed  by  the  vocal,  organs,  there  are  but  four  which 
demand  the  action  of  the  front  portion  of  the  tongue  for  their 
formation,  and  these  are  d,  t,  ^/t,and  /;  it  has  been  found  that  after 
the  removal  of  the  tongue,  all  the  other  primary  sounds  may  be 
formed.  In  absence  of  the  tongue,  attempts  have  been  made  to 
replace  the  organ;  such  an  essay  was  made  by  Ambrose  Pare, 
though  in  a  ruder  way  than  has  been  done  by  the  subsequent 
instrument  maker.     Such  artificial  tongue  has  j^roved  a  failure. 

The  bifid  tongue,  which  is  a  normal  conformation  in  the 
reptile,  dromedary  and  certain  birds,  has  occurred  as  a  congen- 
ital phenomenon  in  the  human  subject;  the  tongue  is  sometimes 
given  a  bifid  form  in  the  removal  of  growths  from  the  part.     The 


010  T()N(;rK. 

treatment  of  congenital  bifid  tongue  consists  in  paring  the 
median  edges  and  uniting  by  suture;  inasmuch  as  many  of  the 
cases  of  bifid  tongue  are  in  tlje  infant  in  Aviiich  many  other 
deformities  coexist,  the  gravity  of  the  latter  is  often  such  that  the 
lingual  imperfections  may  be  neglected:  for  tlie  j)rudent  surgeon 
shoukl  decline  to  become  an  ally  of  fatal  teratology. 

Lingual  Prolaj^sus  ivith  Hypertrophy. — The  tongue  may  be 
enlarged  beyond  its  typical  proportions,  and  this  may  be  coinci- 
dent with  birth,  or  appear  subsequently.  The  abnormal  devel- 
opment concerns  particularly  the  anterior  free  portion  of  the 
tongue,  and  along  with  excessive  volume,  there  is  the  disagreeable 
accompaniment  that  the  tongue  is  protruded  from  the  mouth, 
and  in  this  position,  l:)esides  the  repulsive  appearance  which  it 
gives  to  the  infant,  the  tongue  usualh'  becomes  painful  through 
ulceration. 

Prolapsus  of  the  tongue  was  mentioned  by  Galen,  and  occa- 
sional mention  of  it  occurs  among  inodern  surgical  writers;  Del- 
pech,  Maisonneu  ve,  Clarke,  Syme  and  Beauregard  have  described 
it;  nevertheless,  the  affection  is  a  rare  one;  the  writer  has  seen 
but  one  case  of  it.  It  is  seldom  that  it  has  been  seen  at  birth; 
still,  the  conditions  are  believed  to  exist  then,  which  afterwards 
lead  to  its  development.  As  predisposing  and  causal  conditions 
are  too  great  elevation  of  the  larynx,  abnormal  length  of  the 
tongue,  pertussis,  sucking  the  tongue,  catching  and  compressing 
it  between  the  gums,  and  exaggerated  suction  of  the  nipple. 
Symptoms  which  denote  the  development  of  lingual  ])rolapsus 
are,  that  the  infant  has  its  mouth  constantly  open,  the  saliva  is 
continually  escaping,  and  the  tongue  is  usually  thick. 

The  writer  had  under  observation,  for  a  year,  an  infant  which 
was  the  subject  of  lingual  prolapsus.  At  an  early  age,  this  infant 
was  in  the  habit  of  thrusting  out  its  tongue  and  catching  and 
compressing  it,  at  its  middle  portion,  between  the  alveolar  arches. 
The  result  of  such  compression  was  gradual  enlargement  of  tlie 
tongue,  and  it  was  manifest  that  this  development  was  promoted 
by  the  turgid  condition  in  which  the  tongue  was  maintained. 
The  child  seemed  to  have  pleasure  in  the  act  of  thru.sting  out  and 
compressing  the  tongue.  The  escape  of  saliva,  which  was  con- 
tinual, occurred  because  of  the  open  mouth  and  the  chewing 
movements  of  the  lower  jaw.  The  autlior  was  convinced  from 
what  he  saw  in  this  case,  that  the  affection  was  the  result  of  the 
habit  mentioned,  into  which  the  infant  fell  when  a  few  weeks  old ; 
since  at  that  early  age,  the  infant's  tongue  was  of  normal  volume 
and  was  retained  in  its  mouth. 


LINGUAL    PROLAPSUS.  Gil 

The  lingual  prolapsus,  commencing  in  the  manner  above 
mentioned,  advances  until  the  enlarged  part  remains  protruded 
and  the  jaws  cannot  be  closed.  The  exposed  part  of  the  tongue 
has  a  violet  color,  and  it  is  sometimes  soft  in  consistence;  at 
others,  it  is  indurated.  The  secretions  of  the  mouth  desiccate  and 
form  crusts  on  the  surface  of  the  tongue.  The  deformed  lingual 
]nass  projecting  from  the  mouth  gives  the  subject's  face  a  most 
repulsive  aspect. 

The  continual  gaping  of  tlie  mouth,  and  the  dental  alveoli 
wanting  the  support  of  the  labial  structures,  the  teeth  gradually 
lose  their  position  and  incline  towards  a  horizontal  position. 
The  projected  tongue  also  pulls  on  the  pharyngeal  arches  and 
displaces  them,  as  well  as  the  tonsils,  forwards.  The  non-protruded 
portion  of  the  tongue  remains  nearly  normal  in  volume. 

The  affection  interferes  wnth  breathing,  the  taking  of  food, 
and  the  cleansing  of  the  mouth;  hence  emaciation  and  fetid 
breath. 

As  may  be  inferred  from  what  has  j^receded,  the  primary 
stage  of  prolapsus  is  soon  followed  by  macroglossa  or  hypertrophy 
of  the  tongue.  The  enlargement  of  the  tongue  is  analogous 
to  elephantiasis;  there  is  found  a  cavernous  netw^ork  of  connect- 
ive tissue  filled  with  lymphoid  fluid,  and  in  this  structure  the 
normal  muscular  fibres  may  be  atrophied,  normal  or  magnified 
in  form.  And  the  subjacent  lymphatic  glands  may  be  enlarged. 
In  1853  reports  appeared  upon  the  pathology  of  hypertrophied 
tongue;  the  opinion,  hitherto  held,  that  the  enlargement  depends 
on  enlargement  of  the  muscular  fibres  was  rejected  by  Virchow 
and  others,  "who  found  only  an  augmented  vascular  development; 
the  arteries  are  much  dilated,  and  the  fibrous  or  connective 
tissue  is  hypertrophied.  Cystoid  spaces  are  found,  thought  to  be 
connected  with  t\\e  lymph-vessels. 

Treatment. — The  course  to  be  pursued  will  depend  on  the  stage 
of  the  disease  when  the  case  first  comes  under  observation.  If 
seen  early,  when  tlie  first  signs  of  the  affection  are  appearing  in 
the  infant,  then  it  is  proper  to  make  trial  of  means  which  may 
prevent  growth,  and  reduce  that  which  has  already  occurred. 

In  the  infant  mentioned  seen  by  the  writer,  the  treatment 
consisted  in  strewing  the  surface  of  the  tongue  with  tannin,  and 
having  forced  the  part  into  the  mouth,  it  was  retained  so  by 
means  of  a  properly  applied  bandage,  and  this  was  occasionally 
aided  by  the  nurse's  hand.  This  child,  which  was  a  foundling, 
finally  passed  out  of  sight.     The  observation  made  of  this  case 


G12  TONGUE. 

was  especially  instructive,  since  it  was  evident  that  tbe  prolapsus 
and  growth  had  origin  in  habit;  for  when  the  child  was  not 
guarded,  it  thrust  out  its  tongue  and  compressed  it  between  the 
jaws,  and  in  the  act  it  seemed  to  have  extreme  delight;  such 
satisfaction  as  accompanies  every  act  which  in  the  child  has 
grown  into  a  habit,  especially  a  forbidden  habit.  The  treat- 
ment pursued  in  this  child  produced  but  little  effect. 

Galen  recommended  the  local  use  of  the  juice  of  lettuce,  and 
Louis  claims  to  have  cured  a  girl  by  this  means. 

Treatment  by  compression  was  employed  by  Le  Blanc  and 
Van  der  Haar  by  means  of  a  small  linen  sack  or  pocket  into 
which  the  tongue  was  thrust;  eight  cases  were  said  thus  to  have 
been  cured.  Fairlie  Clarke,  who  has  collected  a  series  of  cases 
of  this  affection,  reports  cures  by  compression.  Syme,  in  1857, 
is  more  favorable  to  compression  than  to  operative  means,  and 
only  after  the  failure  of  compression  Avould  he  operate. 

Lingual  prolapsus  with  hj'pertrophy  has  been  treated  opera- 
tively  in  several  ways,  viz.,  b\''  ligature,  galvano-cautery  and 
excision. 

The  ligature  is  advised  by  Maisonneuve,  and  others;  it  is, 
however,  extremely  objectionable,  since  the  ichor  escaping  from 
the  gangrenous  jjortion  may  pass  to  the  lungs,  and  cause  gan- 
grenous pneumonia.  Besides,  the  removal  by  strangulation 
leaves  an  irregular  surface,  and  has  sometimes  been  followed  by 
recurrence  of  the  hypertrophy. 

The  method  by  thermal  cautery  is  preferable  to  that  by  liga- 
ture, since  the  remaining  surface  will  be  more  regular  in  outline; 
yet  the  cicatricial  surface  which  will  remain  is  not  as  good  as 
that  which  can  be  gotten  by  excision. 

Excision  has  been  practiced  in  three  ways:  in  one  the  tongue 
has  been  cut  off  transversely ;  in  a  second  method,  a  single  cunei- 
form exsection  has  been  done;  and  in  a  third,  a  horizontal  as 
well  as  vertical  wedge-form  excision  has  been  done. 

The  method  of  simply  excising  the  prolapsing  tongue  by  a 
transverse  cut  is  defective,  since  it  leaves  a  broad,  misshapen  sur- 
face of  scar  tissue  uncovered  by  normal  mucous  membrane. 

The  plan  by  a  single  cuneiform  excision  is  preferable  to  that 
just  mentioned,  j'et  is  not  equal  to  the  third  method,  in  which  a 
vertical  and  horizontal  wedge-shaped  section  is  removed:  a  plan 
of  operating  introduced  by  Boyer.  The  result  of  Boyer's  opera- 
tion is  to  restore  the  tongue  to  normal  volume,  and  to  leave  tlie 
part  which  remains  invested  with  its  normal  epithelial  coating. 


AXKYLOGLOSSA.  613 

To  render  the  tongue  accessible  to  the  surgeon's  knife  in  this 
double  excision,  a  strong  thread  should  be  passed  through  the 
base  of  the  tongue,  posterior  to  the  line  of  exsection,  and  tied  so 
as  to  form  a  loop,  which  an  aid  holding  and  making  traction  on, 
the  tongue  can  be  drawn  well  out  of  the  mouth.  While  the  tongue 
is  thus  held,  the  knife,  with  length  sufficient  to  more  than  trav- 
erse the  breadth  of  the  tongue,  is  inserted  as  far  back  as  possible, 
and  by  two  incisions  a  wedge-shaped  portion  is  horizontally 
excised;  then  a  vertical  portion  of  like  form  is  to  be  excised.  In 
this  work  enough  must  be  removed  to  so  reduce  the  tongue  in 
volume  that  it  can  be  returned  and  retained  in  the  mouth;  and 
to  do  this,  it  may  be  necessary  to  remove  a  large  mass  of  structure. 
In  such  an  operation  reported  by  AVutzer,  he  excised  a  mass  of 
structure  which  weighed  over  eight  ounces.  The  hasmorrhage 
which  follows  the  excision  has  been  reported  as  very  considerable 
in  some  cases,  and  was  with  difficulty  controlled;  to  do  so,  AVutzer 
was  compelled  to  resort  to  circular  circumscription,  by  which,  a 
portion  of  lingual  structure  was  also  included  with  the  vessel 

This  double  cuneiform  excision  has  resulted  well  in  nearly 
all  cases;  Syme,  however,  lost  a  case,  in  which  so  much  swelling 
followed  it  that  the  patient  died  from  asphyxia;  against  this 
death,  there  are  twenty-two  recoveries  reported.  In  some  cases 
the  operation  was  not  permanently  successful;  the  hypertrophy 
reappeared,  and  another  operation  became  necessary.  After  such 
recurrence,  Humphry  cured  the  patient  by  compression. 

In  1853,  Humphry  wrote  elaborately  on  macroglossa;  he  col- 
lected twenty-seven  cases  in  literature,  of  which  seven  were  cured 
by  compression,  seven  by  ligature  and  thirteen  by  excision.  In 
the  early  stages,  Humphry  recommends  a  trial  of  compression. 

Ankyloglossa,  or  Tongue-tie. — The  orator  Cicero,  in  his  work  on 
Divination,  refers  to  tongue-tie  when  he  asks:  ''Where  tongues 
are  so  adherent  that  they  cannot  talk,  may  they  not  be  liberated 
by  being  cut  with  a  scalpel?" 

The  tongue  may  be  fastened  to  an  adjacent  wall  on  any  of  its 
sides:  thus  it  may  be  bound  below,  at  its  sides,  or  above.  Lateral 
and  superior  tongue-tie  are  phenomenally  rare  affections;  sublin- 
gual adhesion  is  a  common  occurrence,  and  often  requires  surgi- 
cal aid.  This  subjacent  fixation  of  the  tongue  is  commonly  due 
to  anterior  extension  of  the  normally  present  freenum.  Ordina- 
rily the  frtenum  is  only  about  a  line  in  its  attachment;  but  if  it  be 
much  more  than  this,  and  especially  if  this  band  be  short  in  its 
vertical  length,  then  the  tongue  will  be  hamj^ered  in  its  move- 


014  ToxorE. 

incuts.  There  is  a  popular  notion  that  this  restriction  of  the 
tongue's  movements  will  interi'ore  with  the  child  learning  to  talk; 
such  interference,  however,  is  very  slight.  To  discover  the  amount 
of  the  suhlingual  attachment,  let  the  child's  mouth  he  well  opened, 
Avlieu  the  end  of  the  tongue  can  be  uplifted  with  the  finger,  or  the 
handle  of  a  spoon;  commonly,  the  unusual  manipulation  frightens 
the  infant  so  that  it  screams,  and,  doing  this,  it  fully  exposes  the 
condition  of  the  tongue.  A  little  experience,  however,  will  enable 
the  physician  to  determine  the  state  of  the  tongue  by  merely  insert- 
ing two  fingers  under  the  tongue  so  as  to  include  between  them 
the  frcsnum.  The  treatment  consists  in  dividing  the  extended 
fraenum  with  a  pair  of  blunt  scissors;  and  this  is  most  readily 
done  by  "watching  an  opportunity  when  the  part  is  well  displayed 
during  the  infant's  crying;  thus  the  author  has  frec^uently 
divided  the  frpenum.  The  division  is  sometimes  done  by  means 
of  a  spatula  with  a  fissure  at  one  side,  or  a  grooved  dissector,  which 
has  a  furcated  end.  If  such  instrument  be  used,  let  the  frajiium 
be  caught  between  its  branches,  and  divided  between  the  floor  of 
the  mouth  and  the  instrument.  Instead  of  this  plan,  two  fingers 
may  be  used  for  uplifting  and  fixing  the  tongue.  The  bleeding 
isslight,  unless  by  careless  work  the  floor  of  the  mouth  or  the  lower 
surface  of  the  tongue  is  wounded;  and  through  such  wounding, 
haemorrhage  can  occur,  which  may  demand  control  by  compres- 
sion, or  applications  of  a  styptic. 

The  child  affected  with  congenital  sy{)hilis,  and  being  also  the 
subject  of  tongue-tie,  should  not  be  operated  on.  From  unfortu- 
nate experience  in  such  a  case,  the  writer  desires  to  emphasize 
this  advice.  In  an  infant  several  weeks  old,  in  which  there  were 
secondary  lesions  in  the  anal  and  genital  region,  the  fnenum  was 
divided  to  liberate  the  tongue,  which  was  bound  down  on  the 
floor  of  the  mouth.  A  chancroid  phagedenic  ulceration  was 
developed,  which  extended  to  the  adjacent  mucous  membrane  of 
the  'tongue  and  mouth,  and  this  ulceration  was  only  controlled 
after  months  of  anti-syphilitic  treatment. 

Instead  of  a  thin  fold  of  mucous  membrane,  the  fr?enum  may 
be  a  thickened  mass,  in  fact,  a  species  of  ranula,  of  solid  instead 
of  cystic  structure.  Such  a  development  seriously  interferes  with 
the  function  of  the  tongue.  The  treatment  practiced  in  such 
cases  has  been  to  scarify  or  incise  the  enlarged  structure. 

The  tongue  may  be  adherent  to  the  floor  of  the  mouth  by  its 
entire  inferior  surface;  a  condition  which  renders  the  organ- 
unable  to  accomplish  an}'-  of  its  functions;  and  in  the  new-born. 


GLOSSITIS.  615 

if  unrelieved,  it  would  cause  death  by  starvation,  since  swallow- 
ing of  food  would  be  nearly  impossible;  lastly,  in  the  act  of  deglu- 
tition the  tongue  could  not  recede  and  prevent  the  entrance  of 
food  into  the  air  passages.  Such  adherent  tongue  must  be 
detached  from  the  floor  of  the  mouth  and  reunion  prevented  by 
frequent  separation  of  the  parts. 

Lateral  or  gingival  adherence  of  the  tongue,  m  which  the 
part  is  attached  to  the  surrounding  maxillary  wall,  may  arise 
from  noma,  mercurial  sloughing,  or  from  destruction  of  the 
mucous  surface  from  any  cause.  It  has  been  seen,  though  rarely, 
in  the  new  born.  The  treatment  in  such  case  would  be  to  divide 
the  adherent  parts,  and  maintain  the  liberation  by  sundering  the 
adhesions  as  often  as  they  reformed,  a  task  more  easily  advised 
than  accomplished  in  a  case  of  extensive  adhesion. 

Lapie  describes  the  rare  condition  of  adherence  of  the  tongue 
to  the  palatal  vault,  in  whicli  the  child  was  unable  to  nurse. 
The  treatment  in  such  condition  would  be  to  separate  the  tongue 
from  the  palatal  roof  by  means  of  a  spatula  or  blunt  dissector, 
and  separation  afterwards  maintained  by  detaching  points  of 
re-adherence. 

Glossitis,  or  Inflammation  of  the  Tongue. — The  tongue  may  be 
inflamed  merely  superficially,  or  the  entire  structure  of  the  organ 
may  be  affected. 

Demme,  who  has  made  special  study  of  the  inflamed  tongue, 
gives  the  following  classification  of  the  superficial  form:  (1)  Ca- 
tarrhal, which  may  be  caused  by  a  local  irritation,  or  by  some 
catarrhal  affection  of  the  alimentary  canal;  it  is  indicated  by 
hypersemia,  thickening  of  the  mucous  membrane,  and  cell- 
proliferation.  (2)  Exanthematous,  an  accompaniment  of  an 
exanthema,  and  is  papular  or  vesicular  in  nature.  (3)  Toxaemic 
glossitis,  which  attends  typhoid  fever  and  pyaemia.  (4)  Croupal, 
which  is  seen  in  croupous  disease  of  the  throat  and  air-passages. 
(5)  Dissecting  glossitis,  in  which  irregular  ulcers  appear  on  the 
surface  of  the  tongue. 

Deep  or  profound  glossitis  is  rarer  than  the  forms  just  enu- 
merated; there  are  two  varieties  of  it,  the  phlegmonous  and  the 
muscular;  the  phlegmonous  commences  in  the  sub-mucous  and 
inter-muscular  tissue;  but  in  the  other  variety,  the  muscular 
fibres  are  the  site  of  the  disease.  The  deep  form  may  end  in 
suppuration  and  death  of  tissue,  or  the  event  may  be  cell-growth 
and  the  development  of  fibrous  tissue. 

Glossitis  may  be  unilateral,  or  both  sides  may  be  affected;  it 


616  TONGUE. 

may  also  be  diffused  or  circumscribed.  It  appears  in  acute  or 
chronic  form.  The  epithelium  may  remain  adherent,  or  it  may 
be  detached,  and  in  the  latter  case  there  is  usually  much  pain. 

If  glossitis  be  studied  in  reference  to  its  incipient  symptoms, 
four  types  of  it  may  be  distinguished:  (1)  It  begins  without  any 
general  sym})tonis;  (2)  it  may  be  preceded  and  accompanied  by 
rigor  and  fever;  (3)  it  may  be  accompanied  by  affection  of  the 
mucous  coat  of  the  stomach  and  bowels;  (4)  it  may  be  attended 
by  concurrent  pain  in  the  jaws,  teeth  and  throat. 

In  all  cases  of  deep  inflammation  of  the  tongue,  there  are  pain 
and  swelling,  the  swelling  soon  reaching  a  large  volume;  the 
inflamed  structure  is  red,  tense  and  increased  in  heat,  yet  if  the 
tongue  remains  protruded,  it  becomes  cool.  If  the  tongue  is  com- 
pressed within  the  mouth,  its  sensibility  is  lessened.  In  excep- 
tional cases  the  tongue  has  been  seen  unusually  white. 

When  pus  forms,  the  tongue  is  altered  in  its  form;  it  becomes 
rounder,  unless  the  pus  is  deep  seated.  Sometimes  the  pus 
travels  from  the  upper  anterior  part  to  the  lower  posterior  part 
of  the  tongue.  The  function  of  the  tongue  is  impaired  in  its 
office;  the  acts  of  chewing,  talking  and  swallowing  are  tram- 
meled. There  is  a  feeling  of  tension  and  discomfort  in  the  mas- 
seter  and  temporal  muscles,  and  in  the  joint  of  the  lower  jaw, 
especially  if  one  forcibly  open  the  mouth. 

From  swelling,  especially  if  this  be  in  the  back  part  of  the 
tongue,  respiration  may  be  so  impeded  that  cyanosis  results  from 
defective  admission  of  air  to  the  lungs. 

From  obstructed  circulation,  there  may  occur  oedema  in  the 
floor  of  the  mouth,  in  the  upper  part  of  the  neck,  and  in  the 
palate,  throat  and  epiglottis.  From  the  redema  and  swelling 
cerebral  congestion  and  apoplexy  may  result. 

In  the  acute  form  there  is  high  temperature,  yet  this  is  nearly 
absent  in  the  chronic  form. 

To  epitomize  the  phenomena,  then,  of  a  case  of  glossitis  of 
the  acute  form  vdiich  is  fully  developed,  the  face  is  congested, 
with  oedema  of  the  floor  of  the  mouth,  palate  and  throat;  the 
skin  is  cyanosed  the  expression  of  the  face  is  that  of  extreme 
anxiety;  the  tongue,  as  a  swollen  mass  of  violet  hue,  is  protruded 
from  the  mouth,  and  is  dry;  there  is  cerebral  congestion  and 
mental  stupor;  the  temperature  is  104°  or  105°;  the  pulse  is 
strong  and  rapid,  the  breathing  difficult  and  anxious,  and  the 
skin  is  hot  and  dry;  speaking  is  trammeled,  and  there  is  little 
saliva  in   the   mouth;   and  signs   of  suppuration  soon  appear, 


GLOSSITIS.  617 

unless  a  proper  treatment  early  intervenes.  The  predominance 
of  the  muscular  structure  in  the  tongue,  almost  to  the  exclusion 
of  other  tissues,  which  elsewhere  are  so  intimately  associated 
with  the  suppurative  process,  renders  suppuration  a  rare  event  in 
glossitis. 

In  1856,  Arnold  saw  a  number  of  cases  of  glossitis  in  Wurtem- 
berg,  which  seemed  to  arise  from  some  epidemic  influence,  and, 
in  other  districts,  a  similar  epidemic  influence  prevailed.  In  those 
cases  the  disease  appeared  to  commence  with  a  swollen  point, 
whence  it  extended  and  involved  the  entire  tongue.  The  sub- 
maxillary gland  was  involved  in  some  of  the  patients,  and  sup- 
puration occurred  in  the  floor  of  the  mouth. 

The  writer  has  observed  two  cases  of  glossitis  of  an  extremely 
malignant  type.  In  one,  the  disease  was  preceded  by  erysipelas, 
which  traveled  into  the  mouth,  and  attacked  the  tongue,  which  be- 
came so  swollen  that  breathing  was  interfered  with;  and  the  laryn- 
geal and  tracheal  regions  were  so  involved  or  swollen  that  the 
patient  perished  through  asphyxia.  In  a  second  case,  the  inflam- 
mation involved  the  tongue,  the  floor  of  the  mouth  and  the  upper 
anterior  cervical  region,  and  pus  formed  in  these  parts;  though, 
tracheotomy  was  done,  death  soon  occurred  from  gangrenous 
pneumonia. 

Treatment. — From  the  observation  of  nineteen  cases,  Denime 
claims  that,  nearly  always,  glossitis  can  be  brought  to  a  termina- 
tion by  resolution,  that  is,  dispersion  of  the  neoplastic  elements; 
and  even  where  pus  has  formed,  he  claims  that  its  absorption  can 
often  be  efiected. 

In  the  early  stage  of  the  disease,  the  alimentary  canal  should 
be  emptied  of  its  contents  by  saline  cathartics,  and  astringent 
washes  should  be  used  in  the  mouth;  for  this  purpose  a  solution 
of  tannin,  decoction  of  oak  bark,  or  a  solution  of  alum  may  be 
used.  Ice  should  be  allowed  to  dissolve  in  the  mouth,  and  thus 
the  oral  cavity  be  maintained  at  a. low  temperature.  Ice  may  be 
applied  around  the  neck  and  throat.  Should  the  disease  still 
persist,  local  bleeding  should  be  resorted  to;  for  this,  leeches  have 
been  used,  yet  a  better  plan  is  to  scarify  the  surface  of  the  tongue. 
These  incisions  should  be  antero-posterior  in  direction,  and 
should  penetrate  so  deeply  as  to  cause  free  bleeding.  As  such 
incisions  quickly  contract  through  lessening  of  the  volume  of 
the  tongue,  it  will  be  necessary  to  again  repeat  the  incisions 
after  a  few  hours.  A  third  remedy,  of  which  the  efiicacy  has 
been  lauded  by  Demme,  is  the  local  use  of  the  tincture  of  iodine. 
This  becomes  more  efficacious  in  the  following  combination  : — 
40 


618  TON'GUE. 

li.    Tr.  lodinii  Compos oi 

Tr.  Galhie 5i 

Misce. 
Let  the  tongue  be  painted  with  this  every  four  hours. 

In  a  case  of  glossitis  which  is  developing  rapidW,  the  disease 
may  be  attacked  simultaneously  from  several  sides  by  the  means 
here  detailed,  viz.:  by  purging,  cold,  astringent  gargles,  scarifica- 
tion, and  tincture  of  galls  and  iodine;  and  by  sucli  vigorous  man- 
agement, the  writer  has  seen  the  disease  prom})tly  controlled,  and 
within  a  short  time  the  tongue  was  reduced  to  its  normal  vol- 
ume.    The  incisions  made  soon  heal  and  scarcel}'^  leave  a  scar. 

Abscess  of  the  Tongue. — A  few  cases  of  abscess  within  the  body 
of  the  tongue  have  been  seen  by  the  writer;  and  the  pain  which 
had  preceded  the  sui)puration  was  so  slight  that  it  scarcely 
attracted  tlje  patient's  attention.  In  the  cases  seen,  tliere  had 
slowly  appeard  a  swelling  of  the  tongue,  principally  in  the  central 
part  of  the  organ,  rendering  this  portion  elevated  and  rotund  in 
form.  The  treatment,  in  such  case,  is  to  open  the  abscess  by  a 
longitudinal  incision,  made  as  nearly  as  possible  in  the  median 
line  of  the  tongue;  such  an  incision  wdll  shun  the  blood-vessels, 
or  those  which  might  be  opened  would  not  bleed  much;  for  each 
side  of  the  tongue  has  its  own  system  of  circulation,  and  the 
intercommunication  between  the  two  is  only  of  a  capillary  char- 
acter, except  near  the  apex  of  the  tongue.  Through  the  opening 
made,  the  purulent  content  can  be  forced  out  by  digital  compres- 
sion made  at  the  sides  and  beneatli  the  tongue;  and  since,  in  the 
cases  seen  by  the  writer,  the  site  of  the  pus  was  unilocular,  such 
compression,  after  reopening  the  cavity  once  or  twice,  sufficed  to 
cure  the  patients. 

Ulceration  of  the  Tongue. — The  tongue  may  be  the  site  of 
ulceration;  and  viewed  in  reference  to  causation,  the  following 
forms  present  themselves:  mercurial,  syphilitic,  lupoid,  scrofulous 
or  tubercular,  aphthous  and  traumatic. 

Since  the  era  began  of  the  more  judicious  administration  of 
mercury,  dating  from  about  the  middle  of  the  nineteenth  cen- 
tury, mercurial  ulceration  of  the  tongue  is  a  rare  event;  the 
aquila  alba  (calomel)  of  the  old  alchemists  has  been  so  domesti- 
cated that  its  talons  make  fewer  ravages  in  the  oral  cavity,  than 
was  its  wont  in  olden  time;  still,  such  cases  are  sometimes  met 
with,  especially  in  the  mercurial  treatment  of  syphilis.  This 
condition  is  announced  by  a  swollen,  inflamed  state  of  tlie  alveo- 
lar tissue,  and  redness  of  the  borders  of  the  tongue;  soon  the 


ULCERATION.  619 

mucous  membrane  of  these  parts  breaks  down,  and  a  raw  surface 
is  left.  Meantime,  a  peculiar  fetor,  termed  mercurial  or  metallic, 
proceeds  from  the  affected  parts;  and  there  is  a  profuse  flow  of  a 
fluid  consisting  of  saliva  mingled  with  albuminous  and  epithe- 
lial excreta.  These  phenomena,  in  a  subject  who  is  ushig  mer- 
cury in  some  form,  are  proofs  that  the  remedy  has  exceeded  its 
intended  action;  in  brief,  that  the  patient  is  salivated.  The 
experienced  eye  will  usually  descry  the  coming  ptyalism  at  a 
period  so  early  that  it  may  be  arrested  before  the  aflected  struc- 
tures have  suffered  much  injury:  viz.,  the  mercury  must  be 
discontinued,  the  patient  purged,  a  solution  of  borax  be  used  for 
cleansing  and  disinfecting  the  mouth,  and  a  solution  of  alum, 
viz.,  ten  grains  to  the  ounce,  be  applied  to  the  gums,  borders  of 
the  tongue  and  the  ulcerated  portions  of  the  cheeks.  An  excel- 
lent gargle  for  the  mouth  is  one  composed  of  nine  parts  of  water 
to  one  of  alcohol,  or  spirit  of  camphor.  These  detersive  gargles 
have  done  better  service  for  the  writer  than  the  chlorinated 
solutions  which  are  often  used ;  for  it  has  seemed  probable  that 
the  chlorine  element  in  these  compounds  has  increased  the 
activity  of  the  causal  factor,  mercury.  In  case  the  borders  of  the 
tongue  and  other  affected  surfaces  are  the  site  of  ulceration  which 
is  tardy  in  healing,  then  these  parts  should  be  lightly  touched 
with  a  finely  pointed  pencil  of  nitrate  of  silver;  or  a  crystal  of 
alum  may  be  used  in  the  same  manner. 

Among  the  many  secondary  manifestations  of  syphilis,  lin- 
gual ulceration  is  of  frequent  occurrence;  in  its  wandering  vagaries 
this  destroyer  does  not  omit  the  mucous  membrane  of  the  tongue; 
the  mucous  patch,  the  characteristic  ulcer,  and  the  gummy 
growth  reveal  a  history  which  the  tongue  itself  would  fain  deny. 
The  ulcer,  here  referred  to,  occurs  on  the  margins  of  the  tongue, 
and  most  commonly  on  the  middle  portion  of  the  sides.  This 
ulcer  is  superficial  in  its  character;  and  as  proof  of  its  true  nature, 
there  will  coexist  ulceration  of  a  similar  character  in  other  parts 
of  the  buccal  cavity;  also,  an  examination  will  reveal  the  exist- 
ence of  cutaneous  syphilitic  rashes.  And  this  ubiquitous  mani- 
festation of  mucous  and  dermal  eruptions  distinguishes  clearly 
this  form  of  lingual  ulcer  from  those  of  a  diff'erent  nature. 
According  to  Paget's  publication  of  1858,  the  syphilitic  ulcer  is 
more  clearly  bounded  than  the  scrofulous,  and  is  not  preceded 
by  suppuration;  it  appears  on  the  end  or  sides  of  the  tongue; 
and  is  in  the  form  of  oblique  or  star-like  fissures ;  or  it  has  the 
appearance  of  an  erosion,  of  which  the  central  part  is  the  deepest. 


G20  TONGUE. 

Further  proof  of  its  syphilitic  nature   is  that    it  rapidly  heals 
under  the  u^se  of  iodide  of  potassium. 

Treatment. — The  lingual  syphilitic  ulcer  can  only  be  cured  by 
jjrolonged  constitutional  treatment:  mercury  and  iodine,  singly 
or  combined;  and,  cotemporaneously  with  this,  some  mild  astrin- 
gent, as  a  decoction  of  oak  bark,  may  be  applied,  and  this  may 
be  alternated  with  a  mineral  astringent.  During  this  course,  the 
patient,  if  he  uses  tobacco,  must  wholly  drop  its  use:  if  he  does 
not  do  so,  the  tobacco  will  greatly  retard  the  cure  of  the  syphi- 
litic eruptions  in  the  oral  cavity,  of  whatever  form  these  may  be. 

Ulcer  of  the  tongue  of  a  lupoid  nature  is  sometimes  seen  ;  it 
occurs  oftenest  on  the  edges  of  the  tongue  near  the  epiglottis 
Lupus  never  appears  on  the  tongue  without  already  existing  or 
having  previously  existed  on  the  face.  It  commences  on  the  tongue 
as  small  tubercles  which  soon  break  down  and  present  a  soft  gran- 
ulating base,  which,  healing,  leaves  star-like  scars.  The  proper 
treatment  is  energetic  cauterization,  which  is  best  done  by  means 
of  the  ferrum  candens,  or  the  thermal  cautery.  Along  with  this 
topical  treatment,  the  patient  should  be  given  cod  liver  oil  and 
Fowler's  solution. 

The  tongue  is  not  unfrequently  the  site  of  tubercular  disease. 
Weber,  who  saw  and  studied  the  tubercular  ulcer  of  the  tongue, 
found  that  it  occurs  on  the  border  of  the  latter,  and  is  bounded 
by  irritable,  irregular  edges;  and  from  the  bottom  of  the  ulcer, 
granular,  caseous,  tubercle-like  matter  can  be  expressed.  Cotem- 
poraneous  witli  the  lingual  trouble,  tubercular  affection  of  the 
lymphatic  glands,  ajjices  of  the  lungs,  epididymis  or  rectum  may 
exist.  In  cases  of  tubercular  lingual  ulceration,  the  writer  has 
seen  similar  affection  in  the  anal  and  rectal  region.  In  one 
patient,  besides  the  anal  ulcers,  the  peri-rectal  structures  were 
cribriform  with  fistulse. 

The  tubercular  ulceration  of  tlie  tongue  has  sometimes  been 
mistaken  for  cancer;  and  to  avoid  such  error,  experience  and 
discriminating  judgment  are  requisite.  The  antecedent  or  cotem- 
poraneous  existence  of  tubercular  disease  elsewhere,  will  give 
proof  of  the  true  nature  of  the  disease. 

Trelat,  in  1870;  described  what  he  named  phthisical  ulcer  of 
the  tongue  as  a  forerunner  of  pulmonary  tuberculosis.  He  finds 
this  disease  of  the  tongue  to  begin  from  tubercle-like  bodies  in 
the  surface  of  the  organ;  from  these  develop  ulcers  with  red 
surface  and  ragged  edges ;  before  opening,  however,  these  tubercu- 
lar eminences  have  a  whitish  aspect.     Such  eminences  may  be 


ULCERATION.  621 

agminated  or  isolated.  In  the  subject  of  such  tubercular  emi- 
nences or  ulcers,  other  manifestations  of  tuberculosis  may  often 
be  found. 

Treatment. — Such  ulcer  will  heal  under  the  mildest  treatment, 
provided  the  nutrition  of  the  patient  be  uplifted;  along  with  a 
rich,  generous  diet,  the  only  local  treatment  needed  is  to  maintain 
cleanliness  of  the  mouth  by  frequent  abstersion  with  an  aromatic 
water,  as  mint,  or  cinnamon  water,  or  chamomile  tea;  and  if  a 
local  remedy  be  used,  let  this  be  a  weak  solution  of  the  sulphate 
or  chloride  of  zinc.  As  a  gargle  which  wilL  disinfect  and  facili- 
tate healing,  one  composed  of  five  grains  of  borax  to  an  ounce  of 
water,  may  be  used.  By  such  management,  tongues  have  been 
saved  to  their  owners  which  had  been  condemned  to  excision. 

An  aphthous  ulceration  of  the  tongue  is  not  unfrequently 
seen;  this  consists  of  a  slightly  hollow  breach  of  surface,  which 
is  coated  with  a  thin  layer  of  whitish  gelatinous  material,  which 
is  closely  adherent  to  the  subjacent  surface.  This  diphtheroid 
structure  requires  a  raw  or  wounded  surface  as  a  ground  on  which 
it  takes  root;  and  it  is  doubtless  associated  with  some- microphyte 
as  cause  or  a"lly. 

The  treatment  of  this  form  of  lingual  ulcer  consists  in  fre- 
quent washing  of  the  mouth  with  some  antiseptic  fluid;  for  this 
purpose  one  may  use  aqua  picis  lic|uid8e,  a  decoction  of  the  leaves 
of  Eucalyptus  globulus,  or  the  bark  of  the  wdiite  oak..  And 
should  there  be  seen  collateral  gastric  or  intestinal  derangement, 
this  also  must  have  appropriate  attention. 

Traumatic  ulcer  may  arise  from  any  agency  which  causes  a 
breach  of  surface;,  though  there  are  many  causes  which  fall 
under  this  head,,  the  one  of  most  usual  occurrence  is  an  irregular 
face  or  edge  of  a  sound  or  decayed  tooth.  Such  cause,  though 
unsuspected  by  the  patient,  is  often  revealed  by  a  careful  ex- 
ploration of  the  posterior  teeth  of  the  lower  jaw.  Such  ulcer 
has  irregular  outline,  uneven  surface,  is  often  coated  with  an 
aphthous  formation,  is  extremely  painful;  and  this  pain  is 
maintained  by  the  frequent  movements  of  the  tongue.  As  treat- 
ment for  this,  the  buccal  cavity  should  be  frequently  cleansed 
by  an  antiseptic  solution  selected  from  the  list  above  given.  And 
to  the  ulcer  itself  let  nitrate  of  silver  be  applied,  sparingly,  by  a 
rapid  touch. 

The  various  forms  of  lingual  ulcer  enumerated  are  accom- 
panied by  pain,  which  is  continually  awakened  and  intensified 
by  the  movements  of  the  tongue;  and  the  normal  action  of  the 


622  _  ToxfiuE. 

tongue  in  taking  food  is  so  painful  that  the  patient  abstains  from 
food.  To  lessen  this  difiiculty,  the  food  used  should  be  fluid,  or 
so  liquified  that  it  can  be  swallowed  without  any  preliminary 
preparation  in  the  mouth.  An  excellent  diet  for  such  patients 
may  consist  of  rice,  milk,  eggs  and  broth;  ancl  with  this  some 
wine  may  be  taken;  and  alter  using  food,  the  buccal  cavity,  and 
teeth  should  be  carefully  cleansed;  an  act,  indeed,  which  should 
be  done  in  every  healthy  mouth  after  the  reception  of  food;  for 
thus  doing  the  mouth  would  be  purified,  breath  deodorized,  teeth 
preserved,  and  life  probably  prolonged. 

The  several  formsof  ulcers  which  have  been  treated  of,  though 
they  occur  oftener  in  tlie  tongue,  yet  they  frequently  are  seen  in 
other  parts  of  the  wall  of  the  buccal  cavity;  and,  in  these  differ- 
ent sites,  such  ulceration  demands  the  same  treatment  as  that 
before  explained  for  similar  ulcer  on  the  tongue. 

Grouths  of  the  Tongue. — Besides  the  aberration  from  normal 
form  and  disease  of  tlie  parenchyma  of  the  tongue  already 
described,  the  organ  is  the  occasional  site  of  neoplastic  growths, 
both  benign  and  malignant.  The  benign  class  contains  the  fol- 
lowing species:  vascular,  cystic,  lipomatous,  fibromatous  and 
papillomatous. 

The  vascular  species  consist  of  two  varieties,  similar  to  those 
found  elsewhere:  tlie  superficial  form,  or  telangiectasis,  and  that 
which  involves  the  deeper  structure,  or  tlie  entire  thickness  of 
the  tongue. 

■»  Telangiectasis  of  the  tongue  is  usually  congenital  and  is  often 
so  slight  that  it  may  remain  unseen.  It  may  be  associated  with 
the  deeper  species,  and  then  the  whole  thielvness  of  the  tongue 
can  be  implicated.  Pure  telangiectasis  tends  to  lateral  ratlier 
than  to  deeper  growth.  Expiratory  efforts  tend  to  swell  it  and 
increase  its  red  color;  compression  or  cold  renders  the  surface 
pale,  and  if  it  be  .pricked,  it  bleeds  easily,  and  perhaps  profusely. 
It  may  remain  stationary  for  a  long  time  and  then  suddenly 
grow  to  much  larger  dimensions.  ]Maisonneuve,  who  names  this 
form  of  vascular  growth  erectile  arterial  tumor,  has  observed 
that  it  tends  to  cancerous  degeneration. 

The  deeper  form  of  vascular  tumor,  named  by  Maisonneuve 
the  erectile  venous  tumor,  is  sometimes  congenital.  In  structure 
it  resembles  the  cavernous  body  of  the  penis.  Compression  easily 
effaces  it  tem[)orarily,  and  the  blood  returns  more  tardily  than 
when  the  growth  is  arterial  in  structure.  The  writer  has  seen 
two  examples;  in  one  the  growth  was  at  the  border  of  the  tongue; 


GROWTHS   OF    THE    TONGUE.  623 

iu  the  other  it  was  situated  in  the  median  part  of  the  dorsum  of 
tlie  tongue. 

It  is  seldom,  that  the  vascular  growtli  of  the  tongue,  whether 
it  be  of  the  superficial  or  deep  form,  is  a  source  of  much  incon- 
venience; iu  many  cases  it  has  existed  without  the  subject  of  it 
suspecting  its  existence;  and  where  it  is  thus  free  from  trouble, 
the  guiding  rule  must  be  abstention  from  surgical  interference, 
especially  since  the  growth  may  spontaneously  disappear,  as  was 
observed  by  the  accoucheur  Dubois;  and  only  in  cases  in  which 
it  is  annoying  through  its  large  size,  or  where  from  exposure  of 
the  tongue  to  lesion,  the  subject  is  in  danger  of  haemorrhage, 
should  relief  be  sought  by  some  operative  procedure. 

Treatment. — As  modes  of  treatment  which  have  been  employed 
are  cauterization,  ligation,  ecrasement  and  excision.  Cauteriza- 
tion may  be  done  with  the  hot  iron  or  heated  portion  of  the 
thermal  cautery;  the  latter  is  the  more  convenient,  since  its  action 
can  be  more  exactly  gauged.  Since  extensive  cauterization  may 
produce  sloughs  which  might  be  followed  by  bleeding  when  they 
are  detached,  hence  the  safer  plan  is  to  burn  superficially  and  to 
repeat  the  work  as  soon  as  the  burnt  surface  has  fallen  off. 

If  the  growth  be  of  the  erectile  or  cavernous  type,  cauteriza- 
tion may  be  done  interstitially,  as  Lallemand  did  in  a  case  with 
successful  result;  this  is  done  by  needles,  which,  being  heated  to 
red  heat,  are  thrust  into  the  tumor  at  different  points. 

The  tumor  may  be  circumscribed  by  constricting  ligature, 
which  introduced  by  means  of  a  transfixing  needle,  is  tightly 
tied.  This  plan,  though  effectual  in  result,  has  the  inconvenience 
that  from  the  gangrenous  tissue,  ichorous  material  continually 
escapes  and  is  swallowed,  to  the  detriment  of  general  nutrition. 
Frequent  ablution  of  the  buccal  cavity  will,  however,  partially 
counteract  the  ill  results  from  such  sloughing. 

If  the  vascular  structure  is  so  situated  that  it  can  be  isolated 
by  circumscriptive  constriction,  the  linear ecraseur  may  be  passed 
around  it  and  the  removal  be  effected  without  peril  of  bleeding. 

And  a  fourth  method  is  excision  of  the  affected  part  by  means 
of  the  thermal  cautery,  knife  or  scissors ;  the  method  by  scissors 
the  writer  has  employed  in  a  case  in  which  a  venous  vascular 
growth  was  situated  on  the  border  of  the  tongue;  after  excising  a 
cuneiform  section  the  breach  was  closed  by  a  deep  suture,  which 
remained  in  place  for  a  number  of  days. 

Should  the  vascular  growth  occupy  one-half  of  the  tongue, 
the  proper  procedure  would   be  ligation    of  the  corresponding 


624  TONGUi:. 

lingual  artery;  and  if  the  vasculai'  development  occupy,  on  a  lar^e 
scale,  both  sides  of  the  tongue,  then  the  only  procedure  promis- 
ing a  successful  result  would  be  to  tie  both  lingual  arteries. 

The  tongue  may  be  the  site  of  aneurism,  of  the  circumscribed 
or  diffused  form.  The  strong  pulsation  perceptible  in  such 
tumor,  its  compressibility  and  partial  effacement  by  pressure, 
and  rebound  when  committed  to  itself;  especially,  if  there  be  a 
history  of  some  injury  of  the  tongue,  would  clearly  indicate  the 
true  nature  of  the  affection.  The  pliant  and  yielding  character 
of  the  lingual  tissues,  conjoined  to  the  mobility  of  the  tongue, 
favors  the  continued  enlargement  of  such  aneurismal  tumor;  and 
hence  the  growth  soon  interferes  with  the  function  of  the  tongue. 
The  treatment  which  has  been  proposed  is  direct  compression; 
also,  arterial  ligation;  compression  of  the  tongue  is,  at  best,  an 
ill-manageable  procedure,  and  hence  the  better  treatment  would 
be  ligation  of  one  or  both  of  the  lingual  arteries. 

Cystic  Growths. — Four  varieties  of  cysts  have  been  observed  on 
the  tongue:  the  serous,  mucous,  hydatid,  dermoid  and  athero- 
matous. 

The  serous  cyst  appears  in  all  portions  of  the  tongue;  yet  it 
occurs  oftenest  in  the  base  and  the  inferior  face  of  the  organ.  It 
would  appear  to  commence  from  preexisting  follicles,  whih 
closing,  their  content  continues  to  be  formed.  This  fluid  ii 
clear  and  water-like.  AVhen  the  interior  wall  of  such  cyst  is 
examined,  it  will  be  found  to  be  invested  with  an  epithelium, 
whence  is  excreted  the  serous  content.  This  cyst  appears  as  a 
prominence  uplifting  the  mucous  ^membrane;  and  it  rarely 
becomes  so  large  as  to  annoy  the  subject  of  it.  When  it  occurs 
underneath  the  tonsfue  of  the  infant,  it  maA'  interfere  with  seizino- 
the  nurse's  nipple. 

The  mucous  cyst  originates  in  the  glands  with  which  the 
tongue  is  jjrovided  ;  its  walls  are  thicker  than  those  of  the  serop.s 
species,  and  its  content  is  also  thicker;  it  may  resemble  liquified 
gelatine. 

The  serous  and  mucous  cysts  have  a  resemblance  to  x.m- 
ranula;  the  former  belong  especially  to  the  tongue,  while  ihe 
ranula  has  sublingual  site  in  the  floor  of  the  mouth. 

The  tongue,  as  an  exceptional  event,  has  been  the  site  of  a 
hydatid  cyst;  the  echiuococcus  has  been  seen  here;  such  cyst  is 
distinguishable  from  the  serous  species  only  through  puncture 
and  examination  of  the  content,  in  wliich  the  booklets  of  the 
parasite  will  be  discovered. 


CYSTIC    GROWTHS.  625 

The  treatment  of  these  several  species  of  cystic  tumor  is  much 
the  same:  the  entire  wall  should  be  uplifted  with  a  tenaculum, 
or  toothed  forceps,  and  excised  so  as  to  fully  empty  the  contents; 
and  then  the  remaining  cavity  should  be  cauterized  with  nitrate 
of  silver;  or  what  is  j^et  more  effective,  the  work  may  be  done 
with  the  thermal  cautery;  thus  the  remainder  of  the  wall  will 
be  destroyed,  and  any  secreting  property  it  may  possess,  can  be 
destroyed. 

The  dermoid  cyst,  situated  wholh"  within  the  etructure  of  the 
tongue,  has  rarely  been  seen;  but  such  cyst  has  been  met  with 
under  the  front  of  the  tongue;  thus  Ozenne,  in  1858,  saw  and 
operated  on  a  dermoid  cyst,  situated  here,  and  which  contained 
hair  and  dermal  cells.  He  collected  twenty  similar  cases.  The 
operation  should  consist  in  opening  freely  the  containing  wall, 
evacuating  the  dermoid  content,  and  then,  to  hasten  healing,  the 
wall  of  the  cyst  should  be  carefully  dissected  out.  The  athero- 
matous cyst  may  have  its  site  in  the  sublingual  region,  and  in  its 
development,  encroach  on,  and  become  buried  in,  the  structure  of 
the  tongue.  The  author  has  seen  and  successfully  removed  such 
a  cyst,  which  was  as  large  as  a  hen's  egg,  and  forced  the  tongue 
upwards  and  backwards.  After  removal,  drainage  was  made 
through  the  floor  of  the  mouth. 

Lipoma  has  been  observed  in  the  tongue.  In  1803,  Mason  of 
London  saw  a  case;  also  Maisonneuve  saw  and  dissected  such  a 
tumor;  he  states  that  its  most  usual  site  is  in  the  posterior  and 
inferior  part  of  the  tongue;  a  situation  that  might  be  inferred 
from  the  presence  of  fatty  matter  in  this  portion  of  the  tongue. 
This  lipomatoiis  growth  may  be  pedunculated,  sessile,  or  inter- 
stitial in  site.  Cauchois,  who  saw  a  case  in  1883,  finds  that  its 
site  may  be  submucous,  or  inter-muscular.  This  fatty  tumor  is 
soft,  and  it  may  yield  a  fluctuation  similar  to  that  of  a  cyst  of 
fluid  content.  It  may  attain  considerable  dimensions,  and  may 
ulcerate  at  points,  so  as  to  embarrass  the  diagnosis.  It  has  no 
action  on  the  lym]Dhatic  vessels  which  are  contiguous. 

The  lingual  lipoma  will  never  disappear  spontaneously;  the 
proper  treatment  is  extirpation ;  this  is  readily  done  where  the 
growth  is  pedunculated;  but  if  it  be  sessile,  or  inter-muscular, 
then  an  opening  must  be  made  to  it  from  the  side  at  which  it  is 
most  accessible ;  and  such  incision  should  be  longitudinal,  and 
should  be  as  near  the  median  line  as  possible;  thus  vessels  are 
less  exposed  to  injur}^  If  the  incision  be  deep,  then  it  is  well  to 
close  with  suture.     Laugier  in  1855  reported  the  removal  of  a 


G2G  TONGUE. 

lipoma  from  the  tono-ue,  wliicli  was  done  b}'-  making  an  incision 
through  the  structures  in  which  it  was  encapsulated,  and  then 
simply  enucleating  the  growth.  There  was  no  bleeding  demand- 
ing ligature.  Laugier  remarks  that  lipomatous  growths  are  not 
unusual  in  submucous  tissue;  and  he  thinks  they  are  similar  to 
polypi  in  their  origin. 

Fibroma  of  tJte  Tongue. — Growths  consisting  of  connective  or 
fibrous  tissue  have  been  seen  in  the  tongue;  and  they  occur  there 
oftener  than  the  lipoma.  They  seem  to  occur  oftenest  in  the 
border  of  the  tongue,  though  Erichsen  saw  one  on  the  inferior  face 
of  the  organ.  As  to  relation  with  the  tongue,  they  have  been  seen 
pedunculated,  sessile,  or  situated  within  the  lingual  structure. 
Fairlie  Clarke,  of  Ciiaring  Cross  Hospital,  mentions  such  fibroma 
as  polypoid  in  character,  and  so  situated  as  to  embarrass  or 
obstruct  swallowing.  It  is  oftener  single  than  multiple  in  its 
appearance.  The  fibroma  might  be  confounded  with  the  lipoma ; 
but  since  the  treatment  of  the  two  is  similar,  such  error  in  diag- 
nosis would  have  no  ill  consequence ;  a  more  unfortunate  mis- 
take, however,  would  be  to  excise  a  gummatous  product  under 
the  suspicion  that  it  were  a  fibroma.  Should  there  be  a  suspicion 
that  the  growth  is  syphilitic,  the  true  nature  might  be  determined 
by  subjecting  the  patient  to  an  iodo-mercurial  treatment.'  As  the 
fibroma  continues  to  grow  without  limit,  it  filially  reaches  dimen- 
sions which  disturb  the  patient,  so  that  surgical  relief  is  solicited  ; 
and  for  this,  extirpation  is  the  only  satisfactory  procedure.  If 
pedicled,  it  may  be  removed  after  ligation  of  the  footstalk  ;  if 
sessile  or  interstitial,  remove  the  growth  by  a  circumscribing 
cut,  and  close  the  wound  by  suture. 

Malignant  Growths  of  the  Tongue. — If  the  literature  of  the  lin- 
gual neoplasm  be  studied,  one  finds  that  the  chapter  devoted 
to  the  malignant  genus  has  been  gradually  undergoing  change; 
formerly  one  found  that  writers  recognized  the  existence  here  of 
four  species,  scirrhous,  encephaloid,  melanotic  and  cancroid  or  epi- 
theliomatous;  to-day  the  generic  tree,  by  most  writers,  is  stripped 
of  three  of  its  branches,  and  there  remains  but  epithelioma  as  the 
only  type  of  malignant  growth  appearing  in  the  tongue.  Though 
a  few  authorities  contend  that  both  epithelioma  and  carcinoma 
may  appear  in  the  tongue,  yet  Paget,  Hutchinson,  Thiersch,  Bill- 
roth and  Otto  Weber  find  epithelioma  to  be  the  only  form  of 
malignant  tumor  which  attacks  the  tongue.  And  these  authori- 
ties claim  that  the  only  cases  which  they  have  met  in  which 
carcinoma  was  present  there,  were   those  in  which  the  disease 


MALIGNANT    GROWTHS    OF    THE    TONGUE.  G27 

had  reached  the  tongue  secondarily,  after  having  commenced 
primarily  in  contiguous  structures. 

As  is  taught  by  pathologists,  the  constituent  element  of  the 
epithelioma  is  the  epithelial  element,  disposed  in  horizontal  or 
concentric  layers  superposed  on  each  other.  And  such  cells, 
even  in  stratified  arrangement,  are  sometimes  found  deep  beneath 
the  surface,  so  deep,  indeed,  that  Weber  claims  that  they  have 
arisen  from  connective  tissue  elements;  and  the  same  is  admitted, 
though  unwillingly,  by  Thiersch,  whose  theory  only  allows  of  the 
origin  of  epitheliomatous  cells  from  preexistent  epithelial  cells. 

Epithelial  cancer,  according  to  its  site  or  its  situation  in  respect 
to  the  surface  of  the  tongue,  may  be  grouped  in  two  classes,  viz., 
excrescent  and  internal,  and  each  of  these  may  arise  from  a 
papilla,  wart,  nsevus  or  a  limited  abrasion,  which  may  be  a 
crack,  fissure  or  a  plain  erosion.  And  these  initial  points  of  com- 
mencement, if  examined  early,  have  no  characteristics  of  epi- 
thelioma. 

If  the  unaffected  lingual  papilla  be  examined  histologically, 
the  cells,  which  invest  it,  have  an  arrangement  similar  to  that 
possessed  by  all  other  normal  papillse  of  the  tongue;  but  when 
the  epitheliomatous  change  occurs,  the  papillae  become  radically 
altered  in  their  form;  in  fact,  the  papilla3  become  crowded  out  of 
existence  by  the  invading  strata  or  lines  of  multijDlying  epithelial 
cells. 

In  the  excrescent  papillary  species  the  growth  is  outwards 
rather  than  inwards;  tuberculated,  crested  or  wart-like  promi- 
nences, isolated  or  fused  into  an  uplifted  plateau,  stand  on  a 
hardened  base. 

In  the  internal  form,  besides  growth  outwards,  there  is 
especially  a  development  inwards  of  epithelioid  cells,  which 
penetrate  inwards  between  the  muscular  fibers,  and  along  the 
tissue  which  incloses  the  vessels  and  nerves.  The  invading  new- 
formed  elements  crowd  on  and  destroy  the  muscular  tissue,  and 
the  walls  of  the  lympliatics  and  of  the  blood-vessels.  The  cells 
in  this  deeper  situation  are  more  prominent  than  those  which 
develop  on  the  surface;  the  latter,  from  their  remoteness  from 
nutrient  supply,  and  especially  from  their  exposed  situation,  are 
being  constantly  detached,  so  that  the  uplifted  structure  presents 
a  raw  surface,  and  this  eccentric  or  superficial  growth,  in  sessile 
or  in  pedunculated  site,  rises  often  into  crests  resembling  the 
cock's  comb,  and  is  usually  situated  on  the  dorsal  or  anterior 
face  of  the  tongue,  and  less  often  near  the  epiglottis.     It  may  also 


G28  TONGUE. 

have  a  mulberry  shape,  of  red  tint,  and  bleeding  when  touched. 
The  lingual  epithelioma  of  superficial  site,  occasionally  attains 
inunense  proportions,  too  great  to  be  retained  in  the  buccal 
cavity. 

The  penetrating  species  commences,  according  to  the  author's 
observation,  most  usually  on  the  side  of  the  base  of  the  tongue 
near  one  of  the  ends  of  the  V  which  tlie  calyciform  glands  form 
there;  or,  more  definitely  located, it  begins  in  the  sulcus  between 
tlie  base  of  the  tongue  and  the  palato-glossus  muscle,  and  extends 
thence  upwards  on  the  base  of  the  tongue,  as  well  as  laterally,  on 
the  wall  of  the  pharynx.  This  small  ulcer  always  rests  on  a  hard 
base;  it  is  bounded  by  irregularly  notched  or  jagged  edges,  which 
from  being  undermined,  sink  and  are  infolded.  If  this  ulcerated 
structure  be  compressed  between  the  fingers,  whitich  or  grayish 
vermiform  bodies  are  forced  out,  which, examined  microscopicalh'. 
are  seen  to  be  a  conglomerate  of  epithelial  cells. 

The  ulcerating  process  is  unilateral  and  rarely  crosses  the 
fibrous  median  septum  of  the  tongue,  and  when  situated  posteri- 
orly, in  its  lateral  extension  it  finally  attacks  the  alveolar  process 
of  the  lower  jaw.  Instead  of  this  posterior  site,  it  may  appear  on 
the  free  border  of  the  tongue  anteriorly,  and  at  or  near  the  tip  of 
the  organ.  In  two  cases,  the  writer  saw  the  epithelioma  on  the 
free  border,  midway  between  the  base  and  the  tip  of  the  tongue, 
and  in  a  third,  the  disease  occupied  the  anterior  border  of  the 
tongue  and  extended  backwards  equally  on  each  side,  for  the 
distance  of  a  half  inch  from  the  median  line. 

In  both  the  deep  and  excrescent  forms,  the  ulcerative  process 
finally  reaches  and  opens  blood-vessels,  and  thus  haemorrhage, 
slight  or  profuse,  recurs  and  weakens  the  patient.  The  taking  of 
food  into  the  mouth  and  its  mastication  are  the  source  of  so  much 
j)ain  tliat  the  patient  voluntarily  abstains  from  food,  and  from 
this  cause  he  emaciates  and  loses  strength.  The  decaying,  ichor- 
ous, fetid  materials,  Avhich  are  generated  and  detached  from  the 
ulcerating  surface,  are  partly  swallowed,  or  they  pass  through  the 
windpipe  to  the  lungs;  in  the  former  case,  the  material  being 
ab.sorbed  vitiates  the  blood;  in  the  lungs  such  materials  are  both 
absorbed  into  the  circulation,  and  act  locally  on  the  pulmonary 
structure,  causing  an  adynamic  pneumonia. 

The  morbid  agencies  just  enumerated,  after  some  months,  are 
reenforced  by  the  appearance  of  the  disease  in  the  lymphatic 
glands,  and  this  metastatic  development  corresponds,  as  a  rule, 
to  the  affected  side  of  the  tongue;  only  exceptionally  does  the 


MALIGNANT    GROWTHS    OF    THE    TONGUE.  G29 

metastasis  appear  on  the  opposite  side.  The  gland  or  glands 
which  are  infected,  though  swollen,  are,  for  some  time,  very 
movable;  later,  they  become  adherent  to  the  adjacent  tissues  and, 
finally,  to  the  overlying  skin,  so  that  the  whole  is  a  conglomerated 
mass  of  heterogeneous  structures,  in  which  glands,  muscles, 
vessels  and  nerves  are  almost  indistinguishably  fused  together. 
The  glands  initially  infected  are  those  which  lie  internal  to  the 
angle  of  the  lower  jaw,  and  just  behind  or  below  the  submaxillary 
salivary  gland.  This  fused  conglomerated  structure  later  becomes 
very  closely  adherent  to  the  skin,  which  is  thickened  and  often 
presents  one  or  more  folds  with  depressions. 

There  is  but  little  pain  in  this  morbid  mass  of  secondary 
infection.  The  swollen  glands  are  painless,  and  this  condition 
diverts  both  patient's  and  physician's  attention  from  these  glands 
until  their  presence  is  plainly  declared  by  visible  swelling.  But 
as  the  treatment  and  prognosis  of  lingual  epithelioma  are  inti- 
mately connected  with  the  condition  of  these  glands,  the  latter 
should  be  carefully  examined :  an  examination  which  demands 
skilled  tact  and  care  in  the  early  stage  of  the  disease;  the  one 
finger  on  the  outside  and  one  on  inside  of  the  lower  jaw,  should 
include  and  explore  the  structures  of  the  floor  of  the  mouth,  and 
especiall}^  should  the  region  around  the  submaxillary  gland  be 
examined;  thus  an  indurated  gland  can  be  discovered  if  present; 
and  should  there' be  doubt,  the  normal  condition  of  the  opposite 
side  will  serve  for  corrective  decision. 

The  mass  of  agglutinated  tissues  continuing  to  enlarge, 
finally  the  central  portion  commences  to  soften,  and  at  length 
the  skin  is  opened,  and  an  ichorous  fluid  containing  cheesy  frag- 
ments is  discharged.  This  oj^ening  is  a  small  orifice  at  first,  yet 
it  continues  to  enlarge  until  it  becomes  a  free  crater-like  outlet, 
which  ever  enlarges  without  any  sign  of  healing.  Should  this 
mass  be  removed  before  it  opens,  there  will  be  found  in  it  a  cen- 
tral cavity  containing  softened  material;  the  outlines  of  the  cavity 
are  irregularly  notched  and  jagged,  and  of  dark,  livid  color. 
But  when  such  cavity  is  allowed  to  open,  though  it  discharges 
freely  the  breaking-down  material,  yet  this  has  no  limiting  effect 
on  the  progress  of  the  disease;  the  conglomerated  mass  contin- 
ually incorporates  into  itself  other  tissues  which  are  adjacent  to 
it:  from  the  original  side  invaded,  it  j^asses  to  the  other,  and  the 
front  upper  portion  of  the  neck  is  finally  involved;  and  in  this 
enlarged  field  other  openings  may  form. 

Another  form  of  metastatic  invasion  of  the  structures  of  the 


G30  TONGUE. 

floor  of  the  mouth  and  the  upper  part  of  the  neck  lias  been  seen, 
in  which  there  is  little  or  no  disposition  to  suppuration;  there  is 
swelling  and  rapid  infiltration  of  the  parts  mentioned  ;  the  skin 
remains  white,  and  the  affection  has  no  definite  borders.  It  is 
accompanied  by  an  oedema  at  the  base  of  the  tongue  and  entrance 
of  the  larynx;  and  the  cedematous  swelling  may  quickly  cause 
death  by  occluding  the  glottis.  The  case  here  is  allied  to  the 
purulent  (edema  described  by  Pirogoff,  since,  after  death,  if  the 
aff'ccted  tissues  be  0[>ened  with  the  knife,  there  escapes  a  sero- 
purulent  fluid,  with  which  the  swollen  structures  are  saturated. 

The  course  and  duration  of  lingual  cancer,  if  the  disease  be 
allowed  to  run  its  natural  course,  will,  according  to  Demarquay, 
be  completed  within  fourteen  months,  and  this  brief  period  may 
yet  be  abbreviated,  he  says,  if  the  disease  be  unwisely  attacked; 
for  nearly  all  authorities  report  recurrence  after  operation.  One 
writer,  however,  Otto  Just,  presents  figures  much  more  favorable ; 
he  saj'S  that  recurrence  only  takes  place  in  twenty-five  per  cent 
of  tlie  cases.  The  author  fully  shares  the  opinion  of  Just,  and 
further  believes  that  even  more  than  seventy-five  per  cent  of 
patients  could  be  saved  if  the  disease  were  seen  and  treated  in 
its  jn-imary  stage  by  intelligent  surgery. 

Meddlesome  ignorance  too  often  monopolizes  the  precious 
weeks,  when  proper  treatment  might  rescue  the  patient  from 
death.  Intelligent  management  can  prolong  life,  though  the 
disease  is  not  cured;  for  after  operation  the  average  duration  of 
life  has  been  two  years.  The  absence  of  glandular  metastatic 
infection  adds  much  to  the  prospect  of  non-recurrence;  in  fact, 
this  may  be  regarded  as  almost  a  guaranty  against  return; 

•  In  case  of  relapse,  the  epithelioma  commonly  reappears  at  or 
near  its  primary  site,  or  it  may  appear  in  the  subjacent  glands. 
It  has  been  observed  that  when  the  disease  recurs,  it  grows  at  a 
far  more  rapid  rate  than  it  did  prior  to  the  operation. 

The  causation  of  epithelial  cancer  of  the  tongue  is  unknown; 
it  is  evident,  however,  that  certain  agencies  do  promote  its  evolu- 
tion; as  such  may  be  cited  calcareous  incrustations  on  the  inner 
face  of  the  teeth;  sharp  points  or  edges  of  the  teeth,  which  may 
continually  wound  the  border  of  the  tongue;  and  the  habit  of 
thrusting  the  tongue  into  an  interstice  between  teeth,  or  into  the 
hollow  of  a  decayed  tooth.  The  use  of  tobacco  probably  is  a 
causal  agency,  and  this  explains  the  far  greater  frequency  of  the 
disease  in  the  male  than  in  the  female,  who  seldom  uses  tobacco. 
The  fact  that  the  man  is  less  attentive  to  the  cleanliness  of  his 


MALIGNANT    GROWTHS   OF    THE    TONGUE.  631 

mouth  than  woman  predisposes  the  former  to  epitheliomatous 
affection,  of  ]iot  only  the  tongue,  but  of  the  entire  walls  of 
the  buccal  cavity. 

Age  has  an  important  bearing  in  tlie  development  of  epithe- 
lioma of  the  tongue;  the  disease  seldom  appears  under  forty 
years  of  age;  it  occurs  oftenest  between  forty  and  seventy  years 
of  age,  yet  there  may  be  exceptions  to  this,  since  Billroth  saw  the 
disease  in  a  youth  of  eigliteen  years  of  age. 

Diagnosis. — The  diagnosis  of  lingual  epithelioma  is  of  the 
utmost  importance,  so  that  no  error  in  treatment  may  be  made; 
and  one  unfortunate  error,  which  has  sometimes  been  made,  is 
that- of  confounding  syphilitic  affection  with  cancerous  disease  of 
the  tongue.  To  avoid  such  misapprehension,  the  surgeon  should 
have  a  definite  picture  in  his  mind  of  the  manner  in  which 
sj'philis  affects  the  tongue. 

Syphilis  may  appear  as  the  primary  chancre  on  the  tongue, 
and  then  the  appearances  are  similar  to  those  of  the  disease 
when  it  is  primarily  seated  on  the  mucous  membrane  of  the  lips; 
and  to  test  the  matter,  if  the  chancrous  lingual  ulcer  be  cauter- 
ized and  treated  with  a  mild  astringent,  the  ulcer  will  heal;  but 
if  it  be  cancerous,  such  mild  local  treatment  will  fail  to  heal  the 
lesion.  A  primary  syphilitic  sore  may  heal  spontaneously;  the 
epithelial  ulcer  grows  larger  instead  of  less. 

The  secondary  manifestations  of  S3q3hilis  in  the  tongue,  ac- 
cording to  one  of  the  most  competent  authorities,  Fournier,  ma}'- 
present  themselves  in  one  of  the  following  forms:  (1)  Ulcerating 
syphilide,  or  eruption;  (2)  non-ulcerating,  gummy  eruption; 
(3)  gummy  growth  within  the  tongue.  1.  The  ulcerating  erup- 
tions are  small  lenticular  ulcers,  wiiich  are  round  when  seated 
on  the  dorsal  surface,  but  when  on  the  sides  they  are  more 
irregular  in  shape.  They  appear  solitary,  or  in  groups  of 
crescentic  form;  they  are  indurated  and  chronic  in  duration,  and 
when  they  are  touched,  or  the  tongue  is  moved,  they  are  painful. 

2.  Non-ulcerating  syphilitic  eruptions  of  the  tongue,  named 
also  lingual  sclerosis  or  plastic  glossitis,  present  themselves  in  the 
form  of  round  and  irregularly  shaped  nodules,  which  are  situated 
in,  and  rise  somewhat  above,  the  surface  of  the  tongue.  The 
overlying  mucous  membrane  is  redder  and  smoother  than  tlje 
normal  coating,  and  it  appears  thickened  and  as  if  the  pajnllas 
had  been  removed  from  it.  The  entire  surface  of  the  tongue 
may  be  the  site  of  such  syphilides,  and  then  the  teeth  make 
impressions  on  the  sides  of  the  tongue. 


(ju2  TOXULE. 

3.  Xoniuil  gumma  (better  gummi)  may  develop  in  the  mu- 
cous membrane  of  the  tongue  or  in  the  muscular  tissue  of  the 
organ.  Gumma  lies  in  or  near  the  dorsum  of  the  tongue,  and 
should  it  commence  deeper,  it  grows  towards  the  dorsal  surface. 

There  are  usually  from  one  to  four  gummatous  tumors  in 
the  tongue;  and  they  may  be  small,  or  so  large  as  to  protrude 
the  tongue  from  the  mouth.  It  is  diminutive  when  in  the 
mucous  membrane;  but  when  in  the  muscular  tissue,  it  may 
attain  the  dimensions  of  a  walnut.  Such  gummatous  growth 
may  ulcerate,  and  present  a  hollow  cavity  filled  with  gangrenous 
structure;  and  this  may  remain  open  for  years.  The  lingual 
gumma  is  painless  unless  it  opens;  but  when  it  opens,  speaking, 
chewing,  swallowing  and  other  acts  in  which  the  tongue  is  con- 
cerned, are  interfered  with  and  cause  pain.  The  saliva  is 
increased  in  quantity,  and  the  breath  becomes  fetid.  Taste  is 
unimpaired,  and  the  glands  rarely  swell.  This  is  Fournier's 
description  of  the  syphilitic  eruptions  of  the  tongue,  which  he 
says  may  be  confounded  with  lingual  cancer;  the  latter,  however, 
appears  in  the  old,  while  syphilitic  eruptions  appear  oftener  in 
the  3'Oung  and  robust  subject;  cancer  may  be  inherited,  which 
is  rarely  the  case  with  lingual  syphilitic  manifestations.  Cancer 
retains  its  characteristics,  though  it  becomes  ulcerated  on  its  sur- 
face; and  its  base  has  a  better  defined  induration  than  is  the 
case  with  the  ulcerated  gummy  tumor.  Cancer  appears  on  one 
side,  while  syphilis  is  bilateral  in  its  development.  Lingual 
cancer  is  more  spongy  than  the  syphilitic  growth;  the  former  is 
inclined  to  bleed,  while  the  gummy  growth  is  not.  Cancer  has 
less  steep  edges  than  a  gummy  ulcer;  the  former  granulates  less, 
and  is  not  so  covered  with  gangrenous  tissue,  and  it  has  a  more 
fetid  odor  than  the  gummy  ulcer.  In  the  advanced  period 
of  lingual  cancer,  the  adjacent  glands  become  implicated;  this  is 
rarely  the  case  in  gummy  ulcer.  And  the  author  will  add  that  it 
is  rare  that  secondary  syphilis  has  so  isolated  a  location  as  the 
tongue;  if  found  there,  it  should  manifest  itself  elsewhere. 

Langenbeck  in  1881  gave  the  following  differentiating  marks 
between  syphilitic  gumma  and  lingual  cancer.  Gumma  pre- 
sents one  or  more  rounded  flattened  tumors,  on  which  the 
mucous  membrane  appears  smooth  and  shining;  and  the  remain- 
ing mucous  membrane  presents  a  warty,  fissured  aspect.  Gumma 
appears  in  the  muscular  structure  of  the  tongue,  and  never  in 
the  submucous  tissue  of  the  floor  of  the  mouth.  Multiple  tumors 
indicate  syphilitic  disease.     Cancerous  disease  is   more  painful. 


MALIGNANT    GROWTHS    OF    THE    TONGUE.  633 

iiiid  it  bleeds  easily,  ami  soon  passes  to  the  floor  of  the  mouth, 
where  gumma  does  not  appear.  Laiigenbeck  observed  cases 
in  which  neglected  s^-philitic  disease  of  the  tongue  became 
cancerous. 

Demarcjuay  observes  that  gummy  tumor  of  the  tongue  is,  at 
first,  round  and  hard,  and,  later,  it  softens  at  the  center:  condi- 
tions not  found  in  cancerous  disease. 

Boyer  states  that  cancer  attacks  by  preference  the  sides  and 
point  of  the  tongue,  while  syphilis  appears  oftenest  in  the  median 
part  and  on  the  base  of  the  tongue. 

Treatment. — Epithelial  cancer  is,  in  its  commencement,  a 
purely  local  disease;  and  in  this  stage,  it  is  curable  by  appropri- 
ate treatment ;  but  if  the  disease  be  allowed  to  progress  and  attack 
the  greater  portion  of  the  organ,  and  especially  if  the  glands 
beneath  the  floor  of  the  mouth  have  become  infected,  then  treat- 
ment will  aim  rather  at  palliation  than  eradication  of  the  dis- 
ease. Where  the  disease  already  occupies  all,  or  the  greater  part 
of  the  tongue,  non-interference  should  be  the  guiding  rule ;  in 
such  state,  by  an  attempt  to  remove  the  disease,  the  surgeon's  hand 
would  only  stir  the  fire  and  widen  the  area  of  tiie  flames.  But 
in  all  cases  in  which  tlie  disease  is  circumscribed  to  a  portion  of 
the  tongue  that  can  be  so  operated  on  that  the  track  of  extirpa- 
tion will  be  wholly  within  the  sound  tissues,  then  an  operation 
may  be  resorted  to  with  a  strong  probability  of  curing  the 
patient. 

To  reach  the  tongue  which  is  to  be  operated  on,  if  one  exam- 
ines and  compares  the  methods  of  work  which  have  been  done, 
he  finds  that  three  routes  have  been  used:  through  the  floor  of 
the  mouth,  through  the  mouth  itself,  and,  thirdly,  through,  the 
lower  part  of  the  cheek.  Xumerous  methods  have  been  proposed 
and  pursued  in  the  work  of  extirpation;  though  multifarious, 
these  may  be  comprised  in  the  following  classes:  cauterization, 
potential  and  actual;  ligation,  moderate  or  gradual:  excision  by 
the  knife,  scissors  ecraseur  or  thermal  cautery.  One  or  more  of 
these  methods  finds  illustration  in  the  work  which  has  been 
done  by  eminent  surgeons,  whose  procedures  in  somewhat 
chronological  order  here  follow: — 

In  1842  Regnoli,  to  remove  the  tongue,  made  an  incision 
from  the  os  hyoides  to  the  symphysis  of  the  chin ;  and  then  a 
second  incision  along  the  inner  border  of  the  inferior  maxillary 
arch;  then  through  the  two-flapped  opening  thus  made,  the 
tongue  was  drawn  down,  and  excised.  In  this  way  he  removed 
41 


634  ToxurE. 

tlie  tongue  of  a  girl,  who  recoverecl  so  well  from  the  operation 
that  she  spoke  clearly  and  (.listinctly. 

In  ISoO  Nelaton  found  that  division  of  the  lower  jaw  through 
the  symphysis  was  an  important  aid  in  th'e  operation  of  excising 
the  tongue;  the  jaw  was  divided  by  means  of  a  chain-saw,  and, 
after  the  removal  of  the  tongue,  he  reunited  the  halves  of  the  jaw 
by  means  of  a  ligature,  which  included  the  front  teeth  on  each 
side;  the  incisors  and  canine  teeth  were  tied.  Se'dillot,  in  a  com- 
parison of  Nelaton's  plan  with  that  of  Kegnoli,  prefers  the  former, 
since  it  renders  more  of  the  tongue  accessible  to  the  operator;  he 
thinks,  however,  that  mere  fixation  of  the  sides  by  dental  ligation 
is  an  imi)erfect  plan;  and  to  more  surely  fix  the  parts,  he  would 
so  saw  the  sides  that  one  would  have  a  solid  angle  which  might 
be  received  in  a  hollow  angle  of  the  other  end. 

Near  the  same  period,  Syme  operated  in  somewhat  the  same 
manner  as  Nelaton,  namely,  he  divided  the  lower  jaw  through 
the  symphysis,  and  English  writers  name  this  operation  the 
method  of  Syme. 

In  1858,  Demarquay  operated  in  the  following  manner:  a 
vertical  incision  was  made  through  the  lower  lip,  when  the  lower 
jaw  was  divided  in  the  median  line  with  the  chain-saw^;  the 
tongue  was  excised  with  the  ecraseur,  and  the  divided  bones 
reunited  by  means  of  a  gutta  percha  appliance;  a  complete 
recovery  was  thus  obtained. 

Thiersch,  in  1865,  writing  on  lingual  epithelioma,  finds  that 
it  commences  oftener  on  the  edges  of  the  tongue  than  elsewhere. 
And  since  the  disease  advances  insidiously,  undermining  parts 
which  are  sound,  he  prefers  to  do  the  work  of  removal  with  the 
knife  rather  than  with  the  thermal  cautery  or  the  ecraseur.  As 
a  preliminary  to  the  removal,  he  ties  the  lingual  artery,  which 
he  ligates  near  the  os  hyoides,  fixing  the  latter  with  a  tenaculum, 
as  aid  in  ligating.  In  one  case,  Thiersch  tied  the  right  and  left 
lingual  arteries,  and  in  another  case,  not  finding  the  lingual,  he 
ligated  the  common  carotid  artery. 

Nunneley,  an  English  writer,  in  3  866,  from  his  experience  in 
five  cases  of  cancer  of  the  tongue,  pronounces  the  operation  of 
removing  the  organ  to  be  one  void  o^  peril.  In  three  of  the 
cases,  the  disease  did  not  return.  He  removed  with  the  ecraseur. 
To  do  this,  Nunneley  first  thrust  a  curved  needle  between  the 
hyoid  bone  and  the  lower  jaw,  letting  it  merge  under  the  tongue, 
near  the  frtenum;  by  this  n)eans  the  ecraseur  was  drawn  into  the 
mouth,  and  over  and  behind  the  root  of  the  tongue.     To  aid  in 


MALIGNANT    GROWTHS    OF    THE    TONGUE.  635 

applying  the  ecraseur,  the  tongue  must  be  drawn  well  out  of  the 
mouth.  The  division  of  the  parts  must  be  done  slowly,  so  as  to 
insure  the  closure  of  the  vessels. 

Paget,  to  remove  the  tongue,  first  divides  the  genio-hyoid 
muscles  near  their  insertion  in  the  maxilla  inferior;  through  the 
opening  made,  the  tongue  is  drawn  down,  and  then,  an  incision 
being  made  around  the  tongue  through  the  mucous  membrane, 
the  loop  of  the  Ecraseur  is  placed  in  this  cut,  and  the  division  of 
the  organ  is  now  completed. 

Buchanan,  as  prej^aratory  step,  first  divided  the  lower  jaw  in 
the  symphysis,  according  to  the  plan  of  Ne'laton  and  Syme; 
and  then,  through  this  opening,  he  removed  the  tongue. 

Gamgee,  in  1868,  removed  the  tongue  by  Regnoli's  method,  in 
which  he  separated  the  muscles  from  the  lower  jaw  on  each  side 
as  far  back  as  the  facial  arteries ;  and  he  is  undecided  whether 
this  plan  is  better  than  that  of  Syme,  in  which,  as  preliminary 
step,  the  jaw  is  severed  at  the  symphysis.  He  favors  the  previous 
ligation  of  the  lingual  arteries.  In  1868,  Podrazky,  of  Vienna, 
reported  the  extirpation  of  the  tongue  for  epithelioma,  in  which, 
as  preparatory  step,  he  tied  both  the  lingual  arteries;  and  he 
claims  that  this  was  the  first  time  that  double  ligation  of  these 
vessels  had  been  don^  at  one  time. 

In  1871,  Harrison,  an  English  surgeon,  to  excise  the  tongue 
affected  with  cancer,  first  divided  the  frsenum  and  the  mucous 
membrane  around  the  tongue,  so  that  the  organ  can  be  drawn 
well  forwards.  Through  a  sublingual  opening  made,  the  loop 
of  the  ecraseur  is  to  be  passed,  and  the  tongue  being  included  is 
thus  excised. 

Billroth,  in  1874,  wrote  on  the  removal  of  the  tongue  which 
is  affected  with  cancer.  He  directs  special  attention  to  the 
cleansing  of  the  mouth,  and  urges  that  more  care  be  given  to  this 
than  is  commonly  done.  Through  an  incision  corresponding  to 
the  boundaries  of  the  floor  of  the  mouth,  the  tongue  is  drawn 
and  cut  off  with  scissors,  and  the  vessels  tied  as  they  are  opened. 
The  crescentic  cut  is  next  to  be  closed,  except  its  lateral  endings, 
which  are  left  open  for  drainage. 

Menzel  operated  in  a  similar  way,  yet,  as  a  preliminary,  he 
tied  the  lingual  arteries,  as  advised  by  Czerny. 

Axel  Iversen,  in  1874,  wrote  on  the  operation  of  removal  of 
the  tongue  partially,  or  in  its  totality.  He  opposes  those  meth- 
ods which  mutilate  much  by  extensive  cutting,  viz.,  division  of 
the  maxilla  inferior.     Though  such  mutilating  operation  be  done 


636  TONGUE. 

wliere  thegrowtli  is  far  advanced,  it  does  not  eradicate  the  disease: 
the  latter  soon  recurs.  Iversen  advises  not  to  operate  in  cases  in 
wliich  the  disease  has  extended  beyond  the  papilhc  circunival- 
latie.  Where  the  affection  has  extended  well  backwards,  he 
prefers  the  metiiod  of  Heyfelder  and  Jjiger,  viz.,  to  reach  the 
growtli  by  an  incision  made  through  the  cheek.  Iversen  oper- 
ated on  several  cases,  in  Copenhagen,  in  wliicli  lie  modified 
somewhat  the  cut  of  these  operators,  viz.:  instead  of  incising 
horizontally,  outwards  from  the  angle  of  the  mouth,  he  did 
this  on  a  level  with  the  teeth  of  the  lower  jaw.  Tiiis  cut  curved 
downwards,  so  that  a  convex  flap  was  formed.  Iversen  claims, 
as  advantages  for  this  incision,  that  it  shuns  branches  of  the  facial 
nerve,  avoids  the  duct  of  Stenson,  and  does  not  injure  that  part 
of  the  cheek  in  which  the  tendinous  portion  of  the  facial  mus- 
cles lie;  and  the  wound  made,  having  been  closed  by  twisted 
suture,  heals  by  first  intention.  Iversen  condemns  the  use  of 
the  e'craseur  for  the  excision  as  an  instrument  that  is  uncertain 
and  painful;  but  ho  recommends  the  knife  and  the  galvano- 
cautery.  He  claims,  likewise,  that  tlie  ligation  of  tlie  lingual 
artery  does  not  guarantee  against  lu^jmorrhage.  He  removes  the 
affected  glands,  which  is  easily  done  when  they  are  not  adherent 
to  the  surrounding  structures. 

In  1881,  Guillier,  following  the  method  of  Verneuil,  advises 
thorough  rertioval  of  the  cancerous  tongue  and  at  an  early 
period;  and  should  the  glands  have  become  affected,  he  counsels 
their  removal,  as  well  as  the  removal  of  the  structures  which  lie 
between  the  tongue  and  the  glands.  Recurrence  is  rare  in  the 
lingual  stump;  it  occurs  oftener  in  the  sublingual  tissues  in  the 
floor  of  the  mouth.  To  do  this  work  radically,  let  an  incision 
be  made  through  the  floor  of  the  mouth  from  one  angle  of  the 
lower  jaw  to  the  other;  and  this  cut  demands  the  ligation  of  the 
two  facial  arteries.  A  double  ligature  should  be  placed  on  each 
vessel,  and  the  vessel  then  divided  between  the  ligatures.  Next, 
let  tlie  tongue  be  drawn  down  through  the  crescentic  cut  and 
divided  with  the  thermal  cautery.  If  the  disease  be  unilateral, 
remove  only  the  affected  half  of  the  tongue,  dividing  antero- 
posteriorly  with  the  ^craseur.  In  case  the  palate  and  tonsil  are 
affected,  divide  the  lower  jaw  through  the  symphysis. 

Whitehead  published  in  1881  his  method  of  operating:  he 
dissects  the  tongue  from  the  floor  of  the  mouth,  and  then  divides 
the  organ  near  the  epiglottis,  tying  vessels  as  they  are  di- 
vided. 


MALIGNANT    GROWTPIS    OF    THE    TONGUE.  637 

Berg,  a  kScandinavian,  writing  in  1881,  finds  that  lingual  can- 
cer has  a  special  tendency  to  travel  antero-posteriorly;  exception- 
ally, it  passes  through  the  raphe: — facts  to  be  remembered  in 
operations  on  the  cancerous  tongue. 

In  1881,  Wolfler  describes  the  method  of  operating  then  pursued 
by  Billroth,  who,  within  thirty  months,  had  operated  forty-five 
times.  He  does  not  divide  the  lower  jaw,  nor  make  the  sub- 
mental flap  as  he  once  did,  but  now  operates  through  the  mouth; 
thus  septic  pneumonia  is  warded  off.  He  ties  one  or  both  of  the 
lingual  arteries;  and  the  cut  for  the  ligation  of  the  artery  may 
be  enlarged  and  the  diseased  glands  removed  through  it.  He 
divides  the  freenum  and  mucous  membrane  around  the  tongue, 
so  that  the  latter  can  be  drawn  well  out  of  the  mouth.  Drainage 
is  made  through  the  floor  of  the  mouth.  Wolfler  states  that  the 
secondary  pulmonary  afi'ection,  which  follows  these  operations  on 
the  tongue,  may  be  of  a  mild  catarrhal  character,  which  subsides 
in  a  few  days;  or  there  may  follow  a  severe  pneumonia,  from 
which  the  patient  may  recover;  yet,  sometimes,  death  is  thus 
caused.  The  cause  of  pulmonary  trouble,  in  all  the  forms,  is 
the  swallowing  of  septic  material,  a  part  of  which  passes  to  the 
lungs. 

Langenbeck's  plan  is  to  divide  the  lower  jaw,  and  then  excise 
the  tongue  with  the  thermal  cautery. 

The  method  of  opei*ating  by  Baker,  of  St.  Bartholomew's 
hosiDital,  is  as  follows:  To  hold  and  fix  the  tongue,  a  thread  is 
passed  through  each  side  of  it  a  half  inch  from  the  median  line; 
and  to  loosen  it,  so  as  to  allow  of  extension,  the  attachments  of 
the  tongue  are  divided  with  scissors,  the  divisions  being  done 
close  to  the  lower  jaw.  If  the  disease  be  unilateral,  the  mucous 
membrane  is  to  be  divided  along  the  median  line,  and  the  two 
halves  separated  with  the  finger;  this  done,  remove  the  diseased 
half  of  the  tongue,  and  also  any  glands  which  may  be  affected. 
The  removal  of  the  glands  is  most  easily  done  through  the  floor 
of  the  mouth  by  external  excision. 

Ivocher  operates  by  first  performing  tracheotomy  and  plug- 
ging the  fauces;  then  an  incision  is  to  be  made  along  the  ante- 
rior border  of  the  sterno-cleido  mastoid,  and,  from  the  middle  of 
the  muscle,  carry  a  second  cut  to  the  hyoid  bone,  and  thence 
along  the  digastric  muscle  to  the  symphysis  of  the  jaw.  The  flap 
described  is  reflected  aside,  and  the  facial  artery  and  vein  and 
the  lingual  artery  are  then  tied.  The  attachments  of  the  tongue 
are  next  to  be  severed,  and  the  organ  drawn  through  the  opening 


038  TONGUE. 

and  divided  with  scissors  or  galvano-cauter3^  If  the  entire  tongue 
is  excised,  tie  the  remaining  lingual  artery.  The  canula  must 
remain  in  the  trachea  for  some  days,  and  the  aseptic  dressing  be 
removed  from  the  fauces  twice  daily,  and  new  ones  placed  there; 
and  at  these  dressings  the  patient  must  be  fed. 

In  Volkmann's  plan,  if  the  tongue  can  be  drawn  out,  the 
diseased  portion  is  excised,  and  the  mucous  membrane  brought 
over  tiie  wound,  which  is  closed  by  sutures.  Also,  if  a  portion  of 
healthy  tongue  remains,  this  is  turned  around  so  as  to  form  a 
rounded  end  of  the  lingual  .stump.  But  if  the  tongue  be  more 
extensively  affected,  then  let  a  thread  be  passed  through  it  by 
which  traction  can  be  made.  An  incision  is  then  made  down- 
wards from  the  angle  of  the  mouth;  a  canine  tooth  is  extracted 
and  the  jaw  divided  at  this  point;  through  the  breach,  thus  made, 
the  tongue  can  be  drawn  out  and  excised.  The  cut  surfaces  are 
now  to  be  faced  with  mucous  membrane  and  sutured;  and  the 
jaw  is  to  be  sutured  with  wire.  A  drainage  tube  is  to  be  placed 
in  the  tonsillar  fossa  and  carried  out  through  the  lateral  wound. 
The  writer  thinks  that  Volkmann's  plan  of  dividing  the  lower 
jaw  should  find  few  imitators. 

Near  this  period,  Hueter  and  Lesser  report  extirpation  of  the 
tongue  affected  with  epithelioma.  Seven  operations  are  reported, 
in  all  of  which  the  lingual  artery  was  tied;  and  all  recovered. 

The  operation  of  tying  the  lingual  artery  is  now  generally 
practiced  as  a  preliminary  to  extirpation  of  the  tongue;  and  a 
description  of  how  this  may  be  done  is  here  given. 

From  his  experience  in  this  ligation,  the  author  should  state 
that  it  may  be  easy  or  difficult,  according  to  the  conformation  of 
the  .subject's  neck;  in  those  whose  neck  is  long,  and  with  scanty 
adipose  tissue,  the  artery  is  easily  found;  but  where  the  neck  is 
short,  thick  and  laden  with  a  thick  couch  of  fat,  the  operation 
becomes  extremely  difficult ;  and  it  is  no  wonder  that  one  surgeon 
was  compelled  to  abandon  the  lingual,  and  ligate  the  carotid 
artery. 

Demarquay  in  18G7  reported  the  ligation  of  the  lingual  artery 
in  eight  cases;  and  in  1S68  he  publislied  a  memoir  on  the  sub- 
ject. He  claimed  that  the  operation  was  not  a  difficult  one  to 
one  well  versed  in  the  anatomy  of  the  parts.  He  says  the  opera- 
tion was  first  suggested  by  Beclard  and  was  first  done  l>y  Mirault. 
Besides,  as  a  preliminarv  to  excision  of  the  ton2:ne,  tliis  ligation 
may  be  done  to  control  bleeding  in  the  wounds  of  the  organ:  and 
in  such  cases  the  luemorrhaire  has  not  returned  after  the  ligation. 


MALIGNANT    GROWTHS    OF    THE    TONGUE.  639 

Demarquay  counsels  this  ligature  to  retard  the  growth  in  cases 
ill  which  the  cancer  has  advanced  so  far  that  it  cannot  be 
removed.  At  the  time  he  wrote  his  article  the  ligation  had  been 
done  by  Mirault,  Moore,  Roux  and  Deguise.  To  reach  the  artery 
Demarquay  finds  Blandin's  plan  to  be  the  best ;  this  is  done  by  an 
incision  made  above  the  great  cornu  of  the  hyoid,  and  extending 
from  the  anterior  edge  of  the  sterno-cleido-mastoid  muscle  to  the 
median  line  of  the  neck.  If  the  neck  be  short,  as  soon  as  the 
submaxillary  gland  is  reached,  open  its  capsule  and  let  the 
gland  be  pulled  upwards.  The  digastric  muscle  and  ninth  nerve 
are  now  brought  into  view;  the  artery  lies  in  this  field  in  a 
triangle  formed  by  the  hyoid  cornu  below,  the  hypoglossal 
nerve  above,  and  the  carotid  artery  behind ;  the  artery  lies  just 
above  the  hyoid  bone,  and  is  displayed  by  a  horizontal  cut 
through  the  fibres  of  the  hyoglossus  muscle,  behind  which  the 
vessel  lies  hidden. 

Near  the  same  time  the  lingual  artery  was  tied  by  Hueter  in 
the  operation  of  lingual  excision.  To  find  the  artery,  Hueter 
incises  horizontally  above  the  hyoid  bone,  and,  uplifting  the  skin, 
there  is  displayed  what  he  names  the  lingual  triangle.  This 
triangle  is  bounded  below  by  the  two  legs  of  the  digastric  muscle 
and  above  by  the  hypoglossal  nerve.  The  digastric  portions  are 
the  .sections  of  the  digastric  muscle  which  lie  before  and  behind 
the  hyoid  ^bone.  The  space  included  in  the  triangle  does  not 
exceed  a  square  centimetre  in  surface  (a  centimetre  equals  about 
two-fifths  of  an  inch  in  length).  Hueter  does  not  deem  the 
operation  a  dangerous  one;  on  the  contrary,  Weichselbaum,  who 
has  written  on  the  subject,  pronounces  the  operation  dangerous. 
When  the  disease  occupies  the  middle  portion  of  the  tongue, 
Weichselbaum  advises  to  tie  both  lingual  arteries,  since  accord- 
ing to  Hyrtl,  the  dorsal  portions  of  the  lingual  arteries  some- 
times unite  and  form  a  single  vessel  in  the  median  line. 

Anatomists  have  found  that  the  situation  of  the  lingual  artery 
is  not  uniform  in  the  first  part  of  its  course;  exceptionally, 
instead  of  lying  above  the  hyoid  bone,  it  may  lie  behind  or 
below  it.  If  the  artery  is  not  discoverable,  the  ligation  of  the' 
external  carotid  should  be  done.  The  lingual  should  be  tied  as 
far  backward  as  possible,  since,  done  thus,  no  branches  remain 
through  which  the  blood  can  enter  the  tongue.  Should,  however, 
the  vessel  not  be  discoverable  in  this  part  of  its  course,  or  if  from 
inflammatory  or  cicatricial  agglutination  of  the  structures  the 
vessel  is  not  accessible,  then  it  may  be  sought  for,  more  anteriorly. 


640  TONGUE. 

In  its  anterior  portion  tlie  vessel  may  bo  found  by  making  a 
horizontal  incision  midway  between  the  inferior  margin  of  the 
lower  jaw  and  the  hyoid  bone.  Tiie  exposed  submaxillary  gland 
must  now  be  drawn  upwards  by  a  transfixing  tenaculum;  and 
when  this  is  done,  tliere  is  offered  to  view  the  anterior  leg  of  the 
digMstric  muscle,  and  above  this  the  hypoglossal  nerve;  in  the 
space  between  these,  and  close  beneath  the  hyoglossus  muscle,  lies 
the  lingual  artery.  To  find  the  vessel,  divide  the  hyoglossus 
horizontally,  and  cause  this  cut  to  gap,  and  the  artery  will  be 
found.  This  search  for  the  vessel  will  be  facilitated  if  the  surgeon 
has  recently  dissected  this  region;  for  no  matter  how  accurate  his 
anatomical  knowledge  may  once  have  been,  it  is  within  the 
experience  of  the  writer  that  the  sketches  which  have  been  copied 
in  the  mind  long  ago,  wander,  in  time,  from  the  true  picture  in 
nature;  accurate  correctness  is  only  maintained  by  repeated 
rehearsals  on  the  cadaver. 

As  the  linguist,  who  would  retain  intact  a  language  which  he 
has  learned,  must,  from  time  to  time,  rehearse  his  grammatical 
rudiments,  so  the  operative  surgeon,  to  do  the  best  work,  must 
ever  and  anon  renew  his  early  association  with  the  cadavci".  As 
amnemonic  guide  wliicli  represents  the  site  of  })arts  which  have 
a  close  relation  to  the  lingual  artery,  the  one  subjoined  has  been 
constructed  by  the  writer;  in  the  posterior  site  of  the  vessel  the 
trilogram  CAD  represents  the  initial  letters  of  cornu,  artery  and 
digastric,  in  the  order  in  which  the  structures  stand  from  below 
upwards;  but  anteriorl}^  after  the  artery  has  passed  beneath  the 
posterior  leg  of  the  digastric,  the  symbol  DAN  represents  the 
series  in  which  appear  from  below  upwards,  digastric  muscle,  artery 
and  ninth  nerve;  and  the  two  syllables  conjoined  form  the  word 
CADDAN.  Such  devices,  as  elusive  artifices,  amuse  memory; 
they  become  pebbles,  which,  dropped  into  the  tub  of  the  Danaids, 
close  some  of  the  openings  through  which  are  wont  to  lapse  so 
many  of  the  facts  which  we  store  there. 

As  conclusion  of  the  subject  of  excision  of  the  tongue  for  the 
relief  of  ej)ithelionia  located  in  the  part,  the  writer  will  subjoin  a 
brief  account  of  his  method  of  doing  the  operation.  The  lingual 
artery  is  to  be  tied  on  one  or  both  sides,  according  as  the  tongue 
is  unilaterally  or  totally  affected  with  the  disease.  An  indispen- 
sable aid  in  the  operation  is  to  have  the  lower  jaw  well  depressed 
and  held  so;  and,  for  this  purpose,  the  author  has  devised  and  had 
constructed  an  interdental  gag,  which  is  exhibited  in  the  adja- 
cent illustration.     This  instrument  when  inserted  has  the  ad  van- 


MALIGNANT   GROWTHS   OF    THE   TONGUE. 


641 


Figure  87.     Exhibiting  an  interdental  gag  devised  by  the  writer, 
structed  by  Dr.  A.  B.  McKee.) 


(Con- 


tage  that  it  does  not  encroach  on  the  buccal  cavity;  and  the 
operator  has  untrammeled  access  to  the  tongue.  The  handle  of 
the  inserted  gag  is  held  by  an  assistant  who  also  clasps  and 
steadies  the  head.  The  tongue  is  next  seized  by  strong  clasp- 
forceps  and  pulled  aside  so  that  its  sublingual  and  palato- 
pharyngeal connections  can  be  brought  into  view  and  severed 
with  scissors.  Thus  liberated,  the  tongue  can  be  pulled  well  for- 
wards, when  a  circumscribing  line  is  incised  between  the  affected 
and  unaffected  structures;  and  this  line  must  lie  within  the  sound 
tissues.  Through  this  guiding  incision  the  excision  can  be 
continued  and  completed.  The  part  removed  must  be  examined, 
and  should  it  appear  that  the  disease  has  not  been  wholly 
removed,  the  excision  must  be  continued  further.     The  line  of 


042  TONGUE. 

excision,  if  possible,  should  be  bifid  in  form :  that  is,  the  stump 
should  be  in  two  portions,  which  can  be  closed  by  sutures,  and 
thus  the  wound  be  closed,  and  the  stump  have  a  round  end. 
Thus  done,  the  operation  is  almost  bloodless. 

The  patient  is  to  be  sustained  with  liquid  food.  An  impor- 
tant part  of  the  after-treatment  is  that  the  buccal  cavity  be  often 
cleansed  of  septic  materials  which  tend  to  collect  in  it;  and  fur- 
ther, let  the  cavity  be  frequently  irrigated  with  mint-water,  to 
which  five  per  cent  of  alcohol  has  been  added. 

The  writer  has  performed  the  above  operation  thirteen  times, 
and  eleven  of  the  patients  remain  permanently  cured;  and  their 
power  of  speech  is  not  greatly  impaired. 

In  case  the  tongue  cannot  be  removed,  scrupulous  attention 
should  be  given  to  the  palliative  treatment;  the  patient's  pain 
should  be  reduced  to  a  minimum  by  the  use  of  narcotics.  This  is 
an  humble  field  of  work  in  which  there  are  no  trophies  to  be  won 
by  the  surgeon's  hand,  yet  for  his  heart  there  is  ample  field  for  the 
exercise  of  his  highest  duty  to  his  patient.  The  unfortunate  victim 
of  cancer  is  too  often  ill  cared  for  in  the  last  days  of  his  suffering; 
yetno  case  appeals  more  earnestly  for  kind  and  unceasing  care  than 
does  his;  and  in  this  work  the  surgeon's  hand  should  be  the  first 
and  the  last.  The  slaves  of  the  Aztec  prince  were  slain  to  accom- 
pany their  dying  chieftain,  and  to  carry  lamps  which  should  guide 
his  feet  through  the  dark  vales  of  death :  of  kindred  nature  should 
be  the  devotion  of  the  medical  and  surgical  attendant  to  him 
whose  days  of  agony  linger  seemingly  interminable  before  they 
reach  the  supreme  hour. 

In  the  list  of  anodynes  which  modern  chemistry  has  so  aug- 
mented, no  one  exceeds  o})ium  and  its  comf)ounds  in  eflicac}'; 
the  patient  should  have  morphia  in  doses  increased  correspond- 
ingly, as  tolerance  of  the  remedy  is  developed;  a  quarter  of  a 
grain  should  be  commenced  with,  and  this  be  increased  to  a  half 
grain,  and  finally  a  grain  three  times  a  day.  Nutrient  liquids 
are  to  be  used  as  food.  And  to  lessen  the  pain  of  their  ingestion, 
the  tongue  should  be  cocainized;  in  fact,  as  a  local  anresthetic, 
a  five  per  cent  solution  of  cocaine  may  be  penciled  on  the  raw 
surface,  from  time  to  time.  A  ver}'  efficient  means  of  lessening 
the  pain  is  section  of  the  sensory  lingual  nerve.  In  1866  Colles, 
of  Dublin,  advised  the  section  of  the  gustatory  branch  of  the 
inferior  maxillary  nerve;  and,  as  Hilton  announced,  the  same 
thing  had  previously  been  done  by  him.  This  section  is  done  by 
an  incision  which  is  a  half  inch  behind  the  last  molar  tooth,  and 


WOUKDS    OF    THE    TONGUE.  643 

three- fourths  of  an  inch  below.  This  cut  is  directed  towards  the 
angle  of  the  lower  jaw,  and  must  sever  or  detach  the  soft  parts 
from  the  bone.  The  relief,  obtained  thus,  was  great;  but  as  the 
pain  returned  finally,  Colles  thinks  a  portion  of  the  nerve  should 
be  removed. 

WoufLcls  of  the  Tongue. — The  protected  site  of  the  tongue 
screens  it  from  injury;  nevertheless,  it  is  sometimes  wounded, 
being  reached  by  some  cutting,  penetrating,  contusing  or  burning 
agent.     The  gunpowder  missile  may,  also,  wound  the  tongue. 

According  to  the  author's  observation,  the  tongue  is  oftenest 
wounded  in  the  child  from  falls,  in  which  the  tongue,  being 
thrust  between  the  teeth,  is  caught  and  bitten ;  or  the  child 
having  some  sharp-pointed  object  in  its  mouth,  in  falling,  this 
object  is  thrust  into  the  tongue.  From  these  agencies,  longitu- 
dinal, oblique  or  transvere  cuts  may  originate ;  and  the  wound 
may  be  in  the  body  or  border  of  the  tongue.  In  convulsions, 
epileptic  or  tetanic,  the  tongue  may  be  caught  between  the  teeth 
and  severely  bitten.  And  those  who  have  care  of  such  patients 
should  be  directed  to  prevent  such  accident,  by  interposing  some 
object,  as  a  knife  handle,  piece  of  rubber  or  other  body,  between 
the  teeth,  so  as  to  release  the  tongue,  and,  in  some  measure,  pro- 
tect it  from  injury.  ' 

The  treatment  of  the  open  wound  in  the  tongue  does  not 
differ  essentially  from  that  of  wounds  in  the  dermal  surface  of 
the  body.  The  "wound  must  be  accurately  closed  with  sutures, 
and,  as  far  as  possible,  rest  should  be  given  to  the  part.  To  intro- 
duce the  sutures,  the  tongue  must  be  drawn  out  by  the  aid  of 
clasp-forceps,  and  then  the  edges  of  the  wound  must  be  carefully 
coaptated ;  and  since  the  muscles  of  the  organ  will  move  despite 
its  fixation,  the  adjustment  of  the  wounded  edges  is  not  easily 
done.  Metallic  suture  is  better  here  than  silk;  and,  since  the 
tongue  swelling  buries  the  suture,  and  this  remains  hidden  for 
some  time,  the  wire  should  be  so  cut  that  the  end  of  it  can 
be  found  and  caught,  when  the  time  arrives  for  the  extraction  of 
the  suture.  If  the  tongue  have  been  divided  in  its  entire  thick- 
ness, deep  sutures  must  be  introduced.  If  the  border  be  impli- 
cated, the  first  suture  must  be  placed  there;  thus  proceeding,  a 
notch  or  marginal  irregularity  will  be  avoided.  These  sutures 
must  not  be  closed  too  tightly,  lest  they  cut  the  included  struc- 
ture; and  they  must  remain  in  place  for  a  period  of  a  week,  or 
even  ten  days.  Too  early  removal  of  the  sutures  has  led  to 
failure  through  reopening  of  the  wound.     During   the  time  of 


(544  TONCiUK. 

treatment,  liquid  or  seini-liquicl  food  of  bland  eliaracter  should 
be  given  the  patient. 

In  wounds  of  the  tongue  in  which  a  part  of  the  organ  has 
been  detached,  or  is  merely  adherent  by  a  mere  fibre,  an  attempt 
should  be  made  to  reunite  and  save  the  jtart.  In  1870,  Peltier 
reported  a  few  cases  of  the  kind,  which  he  had  treated  or  had 
observed  in  the  practice  of  others.  The  results  obtained  were 
very  satisfactory;  and  he  accounts  for  this  on  the  ground  that  tlie 
wounds  are  usually  in  children,  in  whom  nutrition  is  in  a  high 
grade  of  integrity.  Also  Beranger  F^raud,  in  his  dissertation  on 
the  reunion  of  parts  which  have  been  severed  from  the  body, 
gives  eleven  cases  of  such  reunion  of  parts  detached  from  the 
tongue.  In  sucli  work  of  restitution  in  cases  in  which  there  has 
been  complete  detachment,  as  well  as  in  those  in  which  the  sep- 
aration is  incomplete,  the  raw  surfaces  should  be  well  cleansed 
before  closure  by  suture. 

Foreign  Bodies  Lodged  in  the  Tongue. — As  before  remarked,  the 
protective  ramparts  around  the  tongue  screen  it  from  injurv  so 
that  wounds  of  it  are  rare;  for  similar  reasons,  the  lodgment  of  a 
foreign  body  in  the  tongue  is  a  yet  rarer  occurrence;  nevertheless, 
the  annals  of  surgery  present  occasional  records  of  such  injury. 
Examples  of  such  are  a  bullet,  a  fragment  of  a  tooth,  fragment  of 
wood  or  a  piece  of  a  pipe-stem. 

The  famous  case  of  Boyer  is  often  repeated,  in  which  a  bullet 
remained  in  the  tongue  for  four  years,  when  it  was  extracted  by 
him.  In  the  extraction  of  teeth,  a  mal-adroit  hand  has  left  a 
fragment  of  a  molar  in  the  tongue;  such  a  case  is  reported  by 
Herbert. 

In  all  cases  of  a  foreign  body  lodged  in  the  tongue,  a  well- 
defined  swelling  occurs  about  the  object,  and  if  this  be  carefully 
ius[)ected,  there  will  be  found  a  breach  of  tlie  surface:  an  opening 
through  which  a  probe  can  be  passed  to  the  body;  or,  this  wound 
may  heal  and  only  a  scar  remain  to  indicate  the  point  of  entrance. 
Such  marks,  with  the  patient's  history  of  an  injury,  will  aid  in 
the  diagnosis;  and  besides  this,  more  definite  knowledge  is  gotten 
by  the  insertion  of  a  probe  or  needle,  by  which  the  body  is  felt. 

The  treatment  of  such  injury  is  to  fix  the  tongue  with  clasp- 
forceps,  and  then  make  an  incision  through  the  surface  of  the 
swelling,  which  will  furnish  the  nearest  approach  to  the  body, 
and  after  the  extraction  of  the  object,  the  wound  will  soon  heal. 

Roof  of  the  Oral  Cavifi/. — The  roof  of  the  oral  cavity  consists 
of  two  portions,  which  differ  in  structure:  the  anterior  part,  which 


ROOF  OF  THE  ORAL  CAVITY.  645 

is  hard,  fixed  and  motionless;  the  posterior  one,  which  is  soft 
and  movable,  and  hence  is  named  the  pendulous  veil  of  the 
palate. 

The  hard  palate  is  a  simple  layer  of  bone  which  is  lined  on 
each  side  by  mucous  membrane,  and  this  membrane  on  the  oral 
side,  is  the  one  which  specially  demands  our  attention,  since  as  a 
passive  agent  it  shares  in  some  of  the  most  complicated  work 
done  by  the  surgeon  in  this  region.  The  bony  roof  ends  in,  and 
is  bounded  on  the  sides  and  front  by,  the  alveolar  process  of  the 
upper  jaw,  and  the  space  included  between  them  is  closely  invested 
by  mucous  and  fibrous  structure,  which  is  continuous  behind  with 
the  pendulous  veil  of  tlie  palate.  The  roof  of  the  mouth,  in  its 
normal  state,  is  a  vaulted  arch,  and  this  arch,  at  its  highest  point 
above  the  dental  plane,  is  from  a  half  inch  to  four-fifths  of  an 
inch  in  height;  yet  Tillaux,  who  has  given  these  figures,  finds 
numerous  deviations  from  them;  the  arch  may  be  low,  and  of 
the  slightly  curved,  Moorish  type,  or  it  may  be  high,  resembling 
then  the  Gothic  form.  In  the  usual  form,  the  longitudinal  and 
transverse  diameters  of  this  vaulted  space  are  of  nearly  the  same 
length;  yet  when  the  vault  rises  Gothic  like,  the  transverse 
diameter  is  lessened;  but  if  the  arch  is  lower,  the  space  becomes 
wider. 

The  mucous  membrane  of  the  palatal  vault  rests  on  a  dense 
stratum  of  fibrous  tissue,  and  in  this  fibro-mucous  structure 
nerves,  glands  and  vessels  lie.  The  nerves  belong  mainly  to  the 
sympathetic  system,  and  descend  from  above  through  the  ante- 
rior and  posterior  palatine  foramina.  These  nerves  are  derived 
from  the  spheno-maxillarysympatheticganglion,  whence  branches 
radiate  in  such  multifarious  directions  as  to  puzzle  or  tire  the  knife 
which  seeks  to  trace  them.  These  branches  are  distributed  to  the 
internal  ear,  the  tonsil,  and  the  soft  and  hard  palatal  structures; 
and  the  anterior  branch  traverses  the  naso-palatine  foramen,  and 
finally  reaches  the  anterior  part  of  the  palatal  vault.  The  site  of 
the  naso-palatine  foramen  is  often  indicated  by  a  wart-like  papilla. 
There  sometimes  exists  here  a  minute  canal  which  traverses  the 
wall,  and  through  which  a  fine  wire  maybe  2:»assed.  Pressure  on 
the  lower  end  of  this  canal  acts  on  the  naso-palatine  filaments 
which  emerge  there.  It  has  been  found  that  pressure  on  this 
part  of  the  palate  wull  arrest  sneezing.  And  use  was  made  of 
this  fact  by  Prochaska;  those  whom  he  had  operated  on  for  the 
removal  of  cataract  were  instructed,  when  they  felt  the  sense  of 
approaching  sneezing,  to  press  with  the  tliumb  behind  the 
incisors  and  thus  arrest  the  act. 


04(3  TONGUE. 

Muciparous  glands  exist  in  the  fibro-mucous  glandular  struc- 
ture; these  glands  are  especially  numerous  in  the  lateral  portions 
of  the  palatal  roof,  and  to  them  is  due  the  increased  thickness  of 
the  fibro-mucous  palatal  structure.  These  glands  are  similar  to 
the  mucous  glands  of  the  lips. 

The  arteries  are  the  posterior  and  anterior  ])alatine,  which 
descend  to  the  hard  palatine  through  foramina  of  like  name. 
These  vessels  sup[)ly  the  nutrition  of  the  osseous  roof  of  the 
mouth.  Tillaux  says  that  any  lesion  which  separates  the  palatine 
fibro-mucous  structure  from  the  overlying  bone  causes  osseous 
necrosis;  evidently  an  error,  for  if  it  were  so,  many  uranoplastic 
operations  would  cause  death  of  the  bone;  yet  such  necrosis  is  a 
rare  event. 

It  is  important  to  study  the  site  of  these  vessels.  The  poste- 
rior palatine  is  a  derivative  of  the  external  carotid  through  the 
medium  of  the  internal  maxillary  artery;  it  is  one  of  the  final 
branches  of  the  latter.  The  vessel  descends  through  the  posterior 
palatine  foramen,  and  emerges  near  to  and  at  the  side  of  the  dens 
sapiens.  After  its  appearance  here,  the  artery  runs  forwards 
along  the  base  of  the  alveolar  process  until  it  meets  the  anterior 
palatine,  with  which  it  forms  inosculation.  In  the  course  of  the 
posterior  palatine  along  the  side  of  the  vault,  the  vessel  lies  in  a 
furrow,  which,  sometimes,  is  converted,  by  a  covering  of  bone,  into 
a  long  canal;  but,  more  frequently, the  vessel  lies  in  a  shallow 
furrow,  or,  at  most,  it  is  not  more  than  half  buried  in  the  bone. 
Branches  are  sent  off  on  each  side;  the  most  of  them,  however, 
pass  inwards  and  forwards.  According  to  Tillaux,  the  position 
of  the  artery  is  such  that  it  can  be  shunned  by  an  incision  cut 
near  the  base  of  the  alveolar  process.  The  cut  should  be  made  thus 
in  the  uranoplastic  procedure;  "for  gangrene  will  never  arise  if 
one  preserve  the  posterior  palatino  artery  in  the  flap." — (Tillaux.) 

Though  no  muscular  fibres  are  contained  in  the  fibro-mucous 
coat  of  the  hard  palate,  yet  wounds  here  gape,  and,  if  a  vessel  be 
opened,  there  will  be  much  bleeding;  and  to  check  this  the 
actual  cautery  is  the  surest  means. 

Behind  tlie  hard  palate  lies  the  soft  one,  which  in  structure  is 
more  complicated  than  the  former.  The  antero-posterior  diam- 
eter of  the  palatal  vault  is  normally  about  three  inches;  of  this, 
one-half  belongs  to  the  hard  jialate  and  the  remaining  half  to  the 
soft  palate.  The  distance  between  the  posterior  border  of  the 
soft  palate  and  the  posterior  border  of  the  pharjaix  is  a  very 
variable  quantity.     The  uvula,  or  posterior  portion  of  the  soft 


INFLAMMATION   OF    THE    1'ALATAI.    STKUCTURES.  647 

palate,  differs  much  in  its  length,  and  from  disease  it  may 
undergo  enormous  elongation. 

The  soft  palate  is  lined  above  and  below  by  mucous  mem- 
brane, and  between  these  lie  muscular,  glandular  and  fibrous 
structures. 

From  underneath,  ascend  and  are  fused  in  the  soft  palate  the 
palato-glossal  and  palato-phryngeal  muscles,  and  its  upper  sur- 
face receives  the  levator  and  tensor  palati  muscles.  The  tensor 
palati  has  recently  been  deprived  of  some  of  the  function  which 
was  once  attributed  to  it;  instead  of  acting  on  the  soft  palate,  as 
formerly  taught,  it  is  now  thought  to  pull  on  the  lower  wall  of 
the  Eustachian  tube,  and  aid  in  maintaining  this  patent. 

The  fibrous  structure  lies  in  the  front  portion  of  the  soft  pal- 
ate, constituting  its  anterior  third.  This  fibrous  structure  lies 
between  the  hamular  processes  of  the  pterygoid  plates,  and  is 
fastened  to,  and  is  continuous  with,  the  posterior  border  of  the 
long  palate;  and  such  is  its  firmness  of  structure  that  one  may 
readily  be  deceived  respecting  the  posterior  limits  of  the  bone: 
viz.,  he  may  suppose  that  the  bone  reaches  farther  backwards 
than  it  really  does.  This  fibrous  portion  may  be  designated  the 
tendinous  origin  of  the  so-named  tensor  palati  muscles.  In 
the  movements  of  the  soft  palate  the  fibrous  layer  does  not 
participate. 

The  glandular  portion  of  the  soft  palate  lies  next  to  the 
inferior  mucous  coat;  though  glands  lie  underneath  the  superior 
mucous  coating,  yet  those  below  are  much  more  numerous,  and 
these  glands  are  the  starting  point  of  the  adenoid  tumors  which 
sometimes  arise  from  the  palatal  veil. 

The  vessels  of  the  soft  palate,  which  are  named  palatine, 
are  derived  from  the  internal  maxillary,  the  facial  and  the 
external  carotid;  and  as  all  the  blood  is  originally  received 
through  the  external  or  common  carotid  arteries,  tense  pressure 
on  either  of  these  will  control  haemorrhage  from  a  wound  of  the 
soft  palate. 

The  lymphatic  vessels  proceed  to  glands  which  are  situated 
at  the  angle  of  the  jaw. 

Inflammation  of  the  Palatal  Structures. — The  palatal  vault  is 
the  site  of  inflammatory  processes,  which  may  arise  primarily 
there;  or  such  process  arising  in  the  adjacent  dental  and  alveolar 
structures  may  extend  to  the  palate.  Those  which  arise  in  the 
alveolo-dental  structures  are  usually  tractable  to  treatment,  and 
do  not  leave  much  trace   of  their  action.     There   is,  however, 


648  TONGUE. 

another  class  wliieli  depends  on  some  constitutional  disease,  and 
often  causes  some  destruction  of  both  osseous  and  soft  structure: 
tiiese  are  scrofula  and  syphilis.  Scrofula  may  develop  Ijere  a 
localized  inflammation,  which  runs  a  long  course,  and  ultimately, 
throufrh  carious  action  or  more  extensive  necrosis,  destroys  a 
l)ortion  of  the  bony  vault.  The  disease  probably  commences  in 
tlie  superior  or  inferior  periosteal  investment  (often  in  the  latter), 
and  it  thence  extends  to  the  bone.  The  site  of  such  periostitis  and 
.subsec|uent  caries  is  commonly  near  the  middle  part  of  the  pal- 
atal vault,  where  the  bone  is  thin,  indeed,  nearly  transparent. 
The  syphilitic  gumma  appears  in  the  same  region,  and  may  end 
in  perforation  of  the  septum  between  the  oral  and  nasal  cavities. 
The  treatment  of  the  cases  comprised  within  these  dyscrasic 
classes  is  that  employed  against  the  constitutional  disease:  to 
wit,  anti-tubercular  and  anti-syphilitic  remedies.  The  chief  cura- 
tive agent  is  iodine,  which,  in  the  form  of  tincture,  should  be 
applied  frequently  to  the  affected  point;  and  iodine  in  some  form 
should  be  given  internally.  Should  the  case  be  syphilitic,  the 
treatment  should  be  iodp-mercurial,  the  details  of  which  are 
given  elsewhere.  The  writer's  experiencejustifies  him  in  expect- 
ing much  from  the  local  use  of  the  compound  tincture  of  iodine. 

In  the  soft  palate  an  inflammation  may  arise  primarily,  or  it 
may  appear  through  propagation  of  an  inflammation  which  began 
in  parts  adjacent.  The  loose  texture  of  the  soft  palate  permits  of 
extensive  swelling,  in  which  the  uvula  is  implicated.  The  swelling 
is  dependent  on  (edematous  infiltration  rather  than  on  accumula- 
tion of  blood  in  the  part.  As  functional  disturbances  from  such 
inflammation  are  cough  and  difficulty  of  swallowing.  Dys- 
phagia arises  from  the  enlargement  and  from  the  partial  loss  of 
the  action  of  the  muscles  in  the  soft  palate  which  are  concerned 
in  deglutition;  and  as  result,  the  choan;e  being  imperfectly  closed, 
food  may  enter  the  nostrils  behind.  The  secretion  of  the  mucous 
glands  is  augmented  and  becomes  more  tenacious  than  normal, 
lience  arises  cough  or  hawking  to  get  rid  of  this  disturbing 
material. 

Treatment. — If  .seen  earl}'  the  treatment  should  be  rigidly  anti- 
inflammatory ;  multiple  scarification  should  be  done  in  the  swollen 
structure;  it  should  be  painted  with  the  following: — 

T^.    Tr.   lodini  C^omp. 

Tr.  Gal'iie aa  li 

Misce. 


AVOUNDS    OF    THE    PALATE.  649 

Fragments  of  ice  should  be  used  and  the  bowels  well  evacuated. 
Treatment  of  this  kind,  commenced  early  and  pursued  diligently, 
may  arrest  the  affection;  as  a  rule,  however,  it  will  proceed  to 
suppuration.  The  pus  is  rather  in  the  form  of  diffused  infiltra- 
tion than  in  well-defined  isolation  from  the  containing  struc- 
tures. It  may  be  discovered  through  the  mucous  membrane  as 
whitish  streaks.  The  treatment  is  to  open  the  affected  structure 
with  properly  directed  incisions,  viz.,  antero-posterior  openings. 
Such  incisions  allow  the  escape  of  existing  pus;  and  they  also 
permit  the  escape  of  serum,  with  which  the  swollen  structures  are 
surcharged.  Extensive  suppuration  may  destroy  so  much  of  the 
palatal  tissue  that  a  perforation  of  the  veil  will  afterwards 
remain;  this  is  rare;  and  the  more  usual  result  is  an  extensive 
scar,  which  by  its  contraction  renders  the  palate  tense  and 
restricted  in  its  motions.  The  orifice  which  remains  may  become 
closed;  yet  the  condition  in  which  the  part  afterwards  remains 
is  not  wholly  satisfactory,  since  the  palate  is  left  abnormally  tense. 

Wounds  of  the  Palate. — However  well  the  palatal  structures  may 
be  secured  from  injury  by  their  position,  still  traumatic  agency 
may  enter  here,  and  implicate  the  soft  or  hard  palate,  or  both. 

The  soft  palate  of  the  child  is  not  unfrequently  wounded  by  a 
sharp-pointed  object,  often  a  toy,  which,  being  held  in  the  mouth, 
is  thrust  backwards  into  the  roof  of  the  buccal  cavity,  by  a  fall 
of  the  child  on  its  face.  Such  injury  tlie  writer  has  seen  caused 
by  a  whistle,  by  which  the  soft  palate  was  pierced  by  a  flap-like 
wound;  and  thus  the  wound  may  vary  in  form  and  situation. 
One  of  the  worst  conditions  is  that  in  which  the  posterior  border 
of  the  veil  is  opened ;  since  the  muscles  on  each  side  greatly  widen 
the  gap  thus  made.  "Whether  the  wound  be  a  marginal  cleft  or 
one  which  perforates  the  veil  anteriorly,  the  pro^Der  treatment  is 
to  close  the  breach  by  metallic  sutures,  as  early  as  possible;  for 
if  thus  done,  the  edges  of  the  wound  being  raw,  they  readily 
unite.  One  or  two  stitches  will  suffice.  If  the  case  be  one  of 
flap-form,  the  edges  should  be  accurately  coaptated,  and  two  or 
more  sutures  introduced,  so  as  to  retain  them  in  place.  If 
accurate  union  cannot  be  obtained,  then  the  pendent,  or  unat- 
tached border  should  be  closely  trimmed  off';  and  thus  a  fringe- 
like scar  is  avoided.  In  case  there  has  been  a  loss  of  structure  in 
the  operative  work  of  closure,  it  will  be  necessary  to  make  lateral 
incisions  so  as  to  permit  disj^lacement  inwards;  of  this  further 
details  will  be  given  hereafter. 

The  bony  palate  mav  be  injured  bv  causes  similar  to  those 
42 


650  iongll;. 

above  mentioned.  Yet  a  greater  degree  of  violence  is  required 
to  perforate  this  part.  8ucli  perforation  has  arisen  from  violent 
contact  with  some  sharp-pointed  object.  The  most  frequent 
causal  agency,  however,  is  the  gunshot  missile;  a  large  portion  of 
the  cases  are  contained  in  the  records  of  military  surgery;  but 
in  the  modern  period  of  suicidal  fashion,  the  pistol  ball  furnishes 
no  small  quota  of  these  wounds.  In  the  statistics  of  military 
wounds  in  the  Crimean  war,  of  two  hundred  and  twenty  wounds 
of  the  fnce,  there  were  nine  perforations  of  the  bony  palate;  and 
in  the  war  in  Italy,  Chenu  reports  that  there  were  ten  perfora- 
tions of  the  palate  in  seventy-seven  wounds  of  the  face.  In  the 
wound  from  a  shot,  there  is  usually  other  injury  of  the  contigu- 
ous parts;  the  ball  in  its  passage  may  wound  the  cheek,  jaw  or 
the  base  of  the  skull;  and  in  the  latter  case,  the  missile  may 
wound  the  brain,  and  cause  an  injury  of  such  gravity,  that  to 
deal  with  the  palatal  wound  would  be  idle  work,  akin  to  that  of 
dressing  a  fracture  on  a  dying  man. 

In  case  the  palatal  bone  is  perforated,  and  fragments  of  bone 
remain  attached  to  the  soft  parts,  the  broken  pieces  should  be 
restored  to  normal  site,  and  the  flaps  of  muco-fibrous  structure 
should  be  retained  in  site  by  properly  placed  sutures.  A  large 
flap  ma}^  thus  possibly  be  saved  and  aid  in  closing  the  breach 
through  the  bone.  Denuce  has  given  the  history  of  a  case 
which  illustrates  what  may  be  done  in  closing  such  a  wound. 
Through  a  suicidal  shot  thefibro-mucous  investment  of  the  bonv 
vault  was  detached  and,  as  a  large  flap,  was  found  hanging 
in  the  mouth;  this  Denuce'  uplifted  and  retained  in  site  by 
sutui'es,  which  were  carried  through  the  breacli  and  the  nares, 
and  fastened  on  the  cheek.     A  satisfactory  result  was  obtained. 

In  brief,  the  immediate  management  of  such  a  case  is  to 
replace  the  osseous  fragments  and  reattach  by  sutures  the  torn 
shreds  of  the  palatal  veil ;  subsequently,  when  the  parts  have 
healed,  some  plastic  procedure  may  be  resorted  to,  to  complete 
the  closure.  At  the  primary  dressing,  however,  an  attempt  at 
com[)lete  closure  may  be  made,  should  this  be  permitted  by  the 
conditions  present. 

Tumors  Arisinr/  from  the  Palate. — Both  the  hard  and  the  soft 
palate  are  the  occasional  sites  of  tumors. 

Aneurism. — The  palatine  artery,  from  pressure  or  direct  trau- 
matic cause,  can  become  the  site  of  an  aneurism;  in  recent  years 
there  have  been  recorded  cases  of  such  aneurism  arising  from 
lesion  due  to  the  pressure  of  the  dental  palate.    Such  aneurism 


ANEURISM.  651 

has  been  cured  by  tbe  actual  cautery;  also  by  opeuing  and 
emptying  the  sack,  after  jDrevious  ligation  of  the  palatine  artery 
on  the  proximal  and  distal  sides  of  the  tumor:  that  is,  by  the  old 
method  of  Antyllus.  Ligation  of  the  external  carotid  artery 
might  also  be  done. 

Pedunculated  or  polypoid  growths  have  been  seen  on  the  soft 
palate;  they  arise  oftenest  near  the  uvula  from  the  posterior 
border  of  the  palatal  veil.  Tliese  growths  often  are  of  such 
diminutive  size  that  they  cause  no  disturbance ;  but  if  thev 
become  large  enough  to  interfere  with  the  function  of  the  part, 
they  should  be  excised. 

Other  growths  have  been  observed  here  of  cystoid  character ; 
such  have  been  seen  by  Robin  and  others,  and  probably  arise 
from  the  closure  of  muciparous  glands.  Cystoid  sacks  contain- 
ing petrified  concretions  have  been  mentioned  by  Parmentier,  in 
1856,  as  occurring  here;  the  origin  of  these  he  finds  in  glandular 
occlusion.  Such  cystic  or  cystlike  tumors  should  be  freely  opened 
and  their  contents  evacuated  by  curetting. 

Solid  growths  of  non-malignant  character  arising  from  the 
palatal  roof  of  the  mouth  have  been  seen  by  Michon,  Nelaton, 
Langenbeck  and  others.  Such  tumor,  as  to  its  structure,  mav  be 
chondroma,  adenoma,  fibroma  or  osteoma,  according  as  the 
cartilaginous,  glandular,  fibrous  or  osseous  elements  2:)redominate 
in  the  composition  of  the  growth. 

The  adenomatous  palatal  tumor  appears  on  the  palatal  veil, 
where  the  glandular  elements  abound;  but  the  chondroma  or 
fibroma  springs  from  the  structures  of  the  bony  vault, 

Langenbeck,  in  1859,  saw  a  case  of  chondroma  here  in  a 
syphilitic  subject  who  was  twenty-seven  years  old.  This  tumor 
had  existed  a  number  of  years,  and  had  grown  to  such  a  volume 
that  it  filled  the  entire  roof  of  the  mouth.  The  growth  was 
easily  removed.  The  writer  in  1870  saw  a  palatal  chondroma  in 
a  young  woman,  which  had  been  many  years  in  its  development, 
and  had  attained  such  dimensions  that  it  filled  the  entire  palatal 
concavity.  It  was  convex  above,  or  rather  a  mould  of  tlie  roof  of 
the  mouth;  and  below  it  was  a  smooth  plane,  on  a  level  with  the 
crown  of  the  teeth;  and  in  length  it  extended  from  the  incisors  to 
near  the  posterior  border  of  the  soft  palate.  This  remarkable 
tumor  was  nearly  white  in  color,  and  was  slightly  movable,  show- 
ing that  it  had  only  a  pedunculated  connection  with  the  palatal 
vault.  The  tumor  was  removed  by  means  of  a  thin-edged  chisel 
which  was  inserted  between  the  front  part  of  the  growth  and  the 


{)0'2  TOXCIE. 

alveolar  process;  the  detaclimeiit  was  thus  easily  done,  and  the 
attachment  was  discovered  to  be  at  the  i)oint  of  union  of  the  four 
angles  of  tiie  j»alatal  process  of  the  palatal  and  superior  niaxillary 
bones,  viz..  at  the  spot  where  the  problem  can  be  solved  of  touch- 
ing at  once  with  the  point  of  a  needle  five  different  bones,  the 
vomer  being  the  fifth  bone.  The  growth  was  probably  due  to 
the  exuberance  of  cartilaginous  formative  material,  which  may 
be  conceived  to  exist  at  such  a  point  of  convergence;  the  osteo- 
genetic  forces  overstepped  the  lines  at  which  their  action  is 
usually  limited;  and  the  surplus  of  cartilage,  the  antecedent  stage 
of  bone,  was  moliled  into  an  enormous  chondroma.  What  was 
remarkable  was  that  so  large  a  development  could  have  grown 
from  so  small  a  pedicle.  This  tumor  did  not  recur.  A  plan 
of  removal  sometimes  resorted  to  is  that  of  cauterization;  this, 
liowever,  is  very  painful,  and  the  better  i)lan  is  to  directly 
extirpate  it;  and  if  it  is  imbedded,  the  containing  capsule  should 
be  opened,  and  enucleation  done. 

Mi{formafioiis  of  the  Soft  and  Hard  Palate;  Acquired  or  Congen- 
ital.— Commencing  posteriorly  the  uvula  is  first  to  be  considered. 
This  terminal  appendage  of  the  pendulous  palate  is  sometimes 
seen  consisting  of  two  portions,  which  meet  and  fuse  at  the  base; 
the  uvula  has  its  cleft  as  well  as  the  palate.  This  uvular  divisitm 
is  probably  the  remnant  of  an  embryonic  cleft  which  has  nearly 
closed  in  utero  ;  or,  viewed  from  another  side,  such  division  may 
be  the  commencement  of  a  palatal  cleft  which  remained  limited 
to  the  uvula.  Such  deformity  causes  so  little  inconvenience  that 
its  existence  is  often  unknown  to  the  patient.  Should,  however, 
anv  disturbance  arise  from  it,  it  would  be  an  easy  task  to  pare 
and  unite  the  parts  by  suture. 

The  uvula  may  become  the  site  of  abnormal  enlargement  in 
which  there  is  thickening  and  elongation.  And  this  may  be  a 
congenital  condition,  or  have  arisen  so  imperceptibly  that  the 
growth  was  unobserved.  In  such  cases  the  abnormally  long 
uvula  may  cause  disturbance  through  contact  with  the  walls  of 
the  pharynx,  or  the  base  of  the  tongue.  This  contact  may 
awaken  a  reflex  movement  and  anno}^  the  patient  by  cougiiing 
and  a  constant  effort  to  clear  out  the  throat.  A  habitual  cough 
may  thus  originate  and  give  suspicion  of  some  organic  disease  of 
the  air-passages.  In  fact,  it  is  claimed  by  a  German  writer  that 
such  continued  irritation  may  awaken  pulmonary  disease. 

The  uvula  may  become  elongated  temi)orarily,through  inflam- 
mation of  the  pharyngeal  walls  which  implicates  the  soft  palate. 


MALFORMATIONS    OF    THE    PALATE.  S53 

Thus  the  uvula  may  become  greatly  lengthened  and  thickened, 
and  greatly  distress  the  patient  through  cough  and  efforts  to 
expel  what  seems  to  be  something  foreign  in  the  throat.  The 
thick,  tenacious  mucus  excreted  by  the  inflamed  mucous  follicles 
is  also  an  irritant. 

Treatment. — The  uninfiamed  uvula  which  is  abnormally  long^ 
should  be  shortened  by  excision.  In  this  work  some  have 
advised  to  remove  the  entire  uvula;  others  recommend  to  pre- 
serve a  part  of  it.  Smith,  in  the  British  Medical  Journal,  in 
1872,  wrote  on  this  subject,  and  recalled  and  recommended  the 
method  announced  twelve  years  before  by  Jearsley,  who  counseled 
to  radically  excise  the  part;  for  he  claims  that  if  a  part  be  left,  the 
scar  on  the  end  of  this  will  maintain  an  irritation.  Smith  advises 
to  remove  with  scissors,  and  to  so  cut  that  the  remaining  scar 
will  be  directed  backwards  and  upwards.  Should  much  bleeding 
follow,  apply  chloride  of  iron,  and  if  this  fails,  ligate.  Smith 
excised  his  own  uvula  with  the  ecraseur,  and  found  that  the 
operation  w^as  a  painful  one.  An  account  is  told  of  a  patient 
who  did  more  than  Smith;  for  the  uvula  of  the  former  being 
greatly  elongated,  he  cut  it  off  with  his  incisor  teeth.  The  method 
of  Smith  and  that  of  his  rival,  though  deserving  worthy  mention, 
will  have  but  few  followers;  the  renown  which  Mucius  Scaevola 
has  in  history  on  account  of  the  self-sacrifice  of  an  arm  is  proof 
of  the  rarity  of  such  temper  among  men. 

The  entire  extirpation,  as  counseled  by  Jearsley,  is  improper, 
since  the  uvula  has  its  function  in  deglutition;  for  it  guarantees 
the  complete  closure  of  the  posterior  nares,  and  thus  insures 
against  entrance  of  fluids  and  solids,  during  swallowing,  into  the 
nose.  In  one  case  in  which  the  writer  had  excised  the  entire 
uvula,  the  patient  was  so  dissatisfied  with  her  condition  that  an 
attempt  was  made  to  restore  the  lost  part.  This  was  done  by 
short  vertical  incisions  through  the  posterior  border  of  the  pendu- 
lous palate,  on  each  side  of  tlie  normal  site  of  the  uvula.  The 
frequent  movements  of  the  soft  palate  retained  the  lateral  cuts 
patent,  so  tljat  a  short  uvular  stump  was  constructed.  In  other 
cases  in  which  the  excision  was  close  to  the  soft  palate,  the 
patient  complained  of  tension  in  the  palate;  he  was  dissatisfied 
with  his  condition,  and  regretted  the  removal  of  his  uvula. 
Therefore,  since  the  uvula  has  the  function  in  deglutition  above 
mentioned,  and  probably  has  another  in  phonation,  by  which  a 
nasal  sound  in  speech  is  lessened  or  avoided,  the  entire  removal 
of  this  appendage  to  the  soft  palate  is  an  error;  there  should  be 
left  a  stump,  at  least,  two  lines  long. 


654  TONGUE. 

The  excision  of  the  uvula  is  best  done  with  a  pair  of  curved 
scissors  and  long-handled  clasp-forceps.  The  patient  is  to  be  so 
placed  that  when  the  mouth  is  well  opened,  the  structures  of  the 
pharynx  are  brouglit  well  into  view;  tlie  uvula  is  then  seized 
near  its  end  with  the  forceps,  which  are  to  be  clasped  so  that  they 
will  not  abandon  their  hold.  The  part  is  then  to  be  drawn  for- 
wards in  the  median  plane,  and  then  to  be  excised  so  that  the 
section  will  be  at  right  angles  to  the  part  and  there  will  remain 
a  stump  of  wliich  the  sides  are  of  equal  length.  The  blades  of 
the  scissors  should  be  sharp,  so  that  they  will  cut  and  not  crush, 
and,  above  all,  will  not  let  the  uvula  slip  from  them.  The  work 
must  be  done  at  one  stroke;  if  done  by  two  strokes,  the  remaining 
surface  will  be  uneven;  one  side  will  probably  be  longer  than 
the  other.  Hence  in  removal  of  the  uvula,  no  rule  deserves  closer 
observation  than  that  the  excision  should  be  done  in  one  act. 

If  the  uvula  be  enlongated  tlirough  inflammation,  as  is  often 
seen  in  pharyngitis,  tonsillitis  and  sometimes  in  diphtheria,  then 
an  attempt  should  be  made  to  reduce  its  volume  by  scarification 
and  astringents.  To  scarify  it,  seize  with  clasp-forceps,  and,  with 
a  pointed  bistoury  or  scalpel,  make  a  number  of  vertical  incis- 
ions in  the  swollen  tissue.  As  local  application,  a  strong  solution 
of  tannin  or  alum  should  be  applied  directly,  or  the  same  may 
be  used  as  a  gargle  when  there  is  general  pliaryngitis.  Should 
these  means  fail  to  return  the  uvula  to  normal  proportions,  then 
it  should  be  removed  in  the  manner  just  described. 

When  the  uvula  has  been  excised,  there  is  slight  bleeding  for 
a  few  minutes;  only  exceptionally  does  this  demand  the  attention 
which  will  presently  be  considered.  A  mouthful  or  two  of  cold 
water,  as  a  rule,  checks  the  bleeding.  Within  a  week  the  wound 
heals,  and  during  this  time  the  patient  may  be  directed  to  rinse 
his  mouth  and  throat  occasionally  with  a  weak  solution  of  borax 
or  chlorate  of  potash. 

As  stated,  exceptionally,  the  excision  of  the  uvula  may  be 
followed  by  continued  bleeding;  two  examples  of  this  have  been 
seen  by  the  writer;  in  one  the  uvula  was  not  inflamed  and  was 
removed  to  get  rid  of  a  troublesome  irritation  in  the  throat, 
caused  by  contact  of  the  part  with  the  base  of  the  toiigue.  The 
patient  was  anemic,  feeble  and  sickly  in  appearance.  The 
removal  of  the  uvula  was  followed  by  very  slight  bleeding,  so 
little,  indeed,  that  at  the  time  no  attention  was  given  to  it,  but  on 
the  following  day  the  man  presented  himself  in  my  office  and 
stated  that  his  "palate"  was  bleeding  and  had  done  so  ever  since 


MALFORMATIONS    OF    THE    PALATE.  GoO 

the  operation.  On  examination  there  was  found  to  be  a  large 
drop  escaping  from  tiie  wound  as  often  as  once  in  every  two 
seconds,  and  the  blood  was  arterial.  This  hsemorrhage  had 
weakened  the  man,  and  it  was  necessary  to  resort  to  some  haemo- 
static procedure;  the  one  chosen  was  ligation,  which  was  done  as 
follows:  The  stump,  which  Iiad  been  left  long  enough  to  grasp 
was  seized  with  clasp-forceps,  and  then  a  silver  wire  was  passed 
around  the  stump  above  the  forceps  and  twisted  enough  to  check 
the  bleeding.  The  wire  did  not  destroy  the  vitality  of  the  small 
portion  of  the  stump  which  lay  beyond  it.  This  ligature  was 
allowed  to  remain  in  site  for  a  week,  when  it  was  removed  and  no 
more  bleeding  ensued. 

Bleeding  occurred  in  a  second  case,  in  which  the  writer  removed 
a  uvula  that  was  elongated,  swollen  and  much  inflamed.  The 
subject  was  a  plethoric  one  with  a  marked  apoplectic  habit.  Some 
hours  after  the  excision  of  this  uvula  the  stump  began  to  bleed, 
and  continued  to  do  so,  until  the  writer  was  called,  who  found 
that  there  had  been  lost  a  considerable  quantity  of  blood.  The 
short  stump  which  had  been  left  did  not  permit  ligation  in  the 
way  in  which  it  was  done  in  the  case  just  described.  A  circum- 
scribing suture  was  passed  by  means  of  a  needle  through  the 
structures  around  the  bleeding  surface;  thus  the  bleeding  was 
controlled,  though  some  difficulty  was  met  in  doing  the  work: 
a  fact  which  the  reader  will  be  fully  convinced  of,  should  he  be 
forced  to  resort  to  either  of  the  plans  here  mentioned,  in  an 
impatient,  indocile  subject,  and  whose  restiveness  is  increased  by 
the  suspicions  that  his  ills  are  due  to  an  error  or  faulty  work  on 
the  part  of  his  surgeon. 

Hence,  as  seen,  though  excision  of  the  uvula  is  usually  one  of 
the  minimum  acts  of  minor  surgery,  it  may,  when  haemorrhage 
follows,  rise  to  a  place  of  no  small  importance  in  surgical  hand- 
work. And  these  exceptional  cases  are  verifications  of  occasional 
experience,  that  the  minutest  breach  in  the  human  organism 
by  a  surgical  instrument  may  be  the  opening  prelude  to  an  event- 
ful drama.  Even  a  simple  suture  may  awaken  a  phlegmonous 
or  erysipelatous  inflammation  which  may  devastate  a  wide  field 
of  the  organism :  ravages,  however,  possible  of  avoidance  by 
timely  care.  As  the  arrow  aimed  at  the  smallest  mark  must  be 
poised  and  directed  with  the  greatest  accuracy,  so  the  minutest 
acts  of  operative  work  should  be  planned,  done  and  afterwards 
cared  for  with  scrupulous  attention,  and,  especially,  vigilance 
should  not  remit  in   the   after-attention.      This  precautionary 


656  TONGUE 

precept  finds  apt  illustration  in  llic  two  cases  of  bleeding  from 
excision  of  tlie  uvula  here  cited. 

Palatal  Adhesion. — The  soft  palate  may  become  adherent  to 
the  phar\'ngeal  wall  above,  so  that  the  choanse  or  posterior  open- 
ing of  the  nasal  passages  can  be  occluded;  and  sucii  occlusion 
may  be  complete  or  incomplete.  When  it  is  incomplete,  the 
adhesion  may  be  unilateral,  bilateral  or  median;  bilateral  adhe- 
sions are  the  most  usual. 

As  causes  which  may  induce  palatal  adhesion  are  the  ulcera- 
tions which  may  originate  from  syphilis,  scrofula  and  lui)us. 
Paul  of  Breslau  has  collected  thirty  cases  of  such  adhesion,  of 
which  twenty-six  were  due  to  syphilis;  in  tlie  few  cases  seen  by 
the  writer,  the  cause  was  scrofula.  Total  adhesion  is  rare,  but 
partial  is  not  infrequent. 

Such  fixation  of  the  soft  palate  causes  interference  with 
breathing  and  swallowing.  In  case  of  complete  closure,  respira- 
tion is  greatly  interfered  with;  the  patient  can  only  breathe 
through  the  mouth,  a  condition  which  is  not  only  disagreeable, 
but  it  exposes  the  lungs  to  tlie  action  of  cold  air,  which  might 
be  tempered  with  warmth  if  it  traversed  the  nasal  passages. 
Such  total  closure  prevents  the  detachment  and  removal  of  the 
excreta  which  tend  to  collect  in  the  nasal  passages;  the  expulsive 
effort  cannot  be  made  by  which  such  materials  can  be  dislodged 
and  ex[)elled.  Breatliing  tlirough  the  mouth  dries  the  tongue 
and  the  mucous  membrane  lining  the  buccal  cavity.  The  voice 
is  also  soraewljat  changed. 

In  case  there  remain  some  opening,  these  several  impairments 
of  function  are  lessened  in  degree;  the  patient  can  probably 
breathe  through  the  nose,  which  to  him  is  a  great  boon;  for 
patients,  in  whom  the  occluded  nasal  passages  had  been  reopened, 
have  assured  me  that  to  breathe  again  tlirough  the  nostrils  was 
one  of  the  greatest  pleasures:  an  illustration  of  the  great  value 
of  a  seemingly  unimportant  part  of  the  body;  but  if  once  lost, 
such  part  perforce  reveals  its  importance. 

Palatal  adhesion  impairing,  as  it  does,  voice,  taste,  smell, 
swallowing  and  the  power  to  clear  the  nostrils,  demands  surgical 
attention;  the  choanse  must  be  reopened.  The  work  can  be  done 
partly  through  the  mouth,  and  partly  through  the  inferior  nasal 
meatus.  By  the  mouth  one  may  enter,  and  with  a  blunt  instru- 
ment similar  to  a  raspatory,  the  separation  can  be  efiected.  In 
case  the  adherence  be  extensive,  it  will  be  easier  to  do  some  of  the 
work  from  above  through  the  nose.     For  this  purpose  a  blunt- 


DESTRUCTIOX    OF    THE    UVULA    AXD    SOFT    PALATE.  657 

edged  instrument  with  a  handle  curved  similar  to  that  of  the 
palatal  arcli,  may  be  passed  into  the  nose  and  made  to  descend 
down  the  wall  of  the  pharynx,  and  separate  the  palatal  structures. 
In  his  student  davs  the  writer  saw  a  case  in  which  durino-  the 
operation  his  preceptor,  Dr.  Cooper,  cut  a  twig  from  a  pear  tree 
which  stood  near  the  window,  and  having  trimmed  one  end  into 
a  blunt  edge,  this  was  carried  along  the  floor  of  the  nose  until  it 
reached  the  posterior  cul-de-sac,  when,  being  thrust  onwards,  it 
passed  down  the  posterior  pharyngeal  wall,  and  soon  appeared 
in  the  throat;  and  by  further  work  with  the  happily  imj^rovised 
instrument,  the  palatal  structures  were  liberated  from  their  attach- 
ments. A  piece  of  whalebone,  similarly  trimmed,  might  be  used, 
especially  if  it  be  softened  in  hot  water,  curved  and  allowed  to 
cool.     No  haemorrhage  attends  the  w'ork. 

The  reestablishment  of  the  occluded  posterior  nares  will  be 
found  a  tedious  procedure,  and  the  subsequent  maintenance  of 
permeability  will  be  a  yet  more  emijarrassing  task;  for,  thouo-h 
the  passage  be  well  opened,  without  subsequent  precautions  it 
will  Cjuickly  reclose.  The  position  of  the  parts  renders  it  impos- 
sible to  invest  the  raw  surface  with  a  mucous  coat,  an  indispen- 
sable requisite  to  prevent  reclosure;  hence  the  wounded  parts 
must  be  maintained  asunder  until  they  cicatrize.  To  do  this, 
carry  along  the  floor  of  the  nostrils  a  cord,  to  the  distal  end  of 
which  when  seen  in  the  fauces  a  plug  of  lint  is  fastened;  thus 
a  temporary  tampon  can  be  placed  in  the  choanse;  and  this 
must  be  done  daily  for  many  w^eeks.  Finally,  if  this  plan  be 
patiently  pursued,  the  part  becomes  invested  with  a  cicatrized 
surface;  and  since  scar  tissue  tends  to  contract,  the  introduction 
of  the  obturating  plug  must  be  continued  for  some  time  longer; 
and  at  length  it  need  be  introduced  only  occasionally,  until  finally 
the  opening  will  remain  permanent.  The  writer  would  suggest 
that  the  j^atient  would  be  more  tolerant  of  the  work,  as  well  as 
encouraged  in  its  action,  if  the  obturator  were  traversed  by  a  tube 
so  that  the  air  could  pass  through  it  in  respiration. 

Destruction  of  the  Uvula  and  Soft  Palate. — Sjq^ljilitic,  scrofulous, 
lupous  and  malignant  disease,  through  destructive  ulceration,  may 
destroy,  partly  or  wholly,  the  uvula,  as  well  as  the  soft  palate.  In 
the  unfortunate  event  that  both  these  structures  be  totally 
destroyed,  it  is  probable  that  no  operation  which  the  surgeon 
might  perform  could  furnish  relief;  such  cases  would  fall  within 
the  province  of  the  dental  mechanician;  and  it  is  j^robable  that 
even  his  most  ingenious  device,  though  phonation,  breathing  and 


G.38  TONGUE. 

smell  might  be  aided  thereby,  would  be  found  a  poor  substitute 
for  the  lost  parts,  and  be  a  disappointment  to  the  patient;  still, 
such  appliance  is  better  than  nothing,  and  probably  better  than 
what  could  be  gotten  through  the  essays  of  tlie  surgical  plasti- 
cian:  the  work  of  the  latter  might,  however,  find  place  where 
the  destruction  had  been  incomplete. 


CHAPTER  XIX. 


PALATAL    CLEFT    OR    DIVISION. 


Palatal  cleft  may  be  congenital,  or  accidentally  acquired. 
Congenital  cleft  may  involve  both  the  soft  and  the  hard  palate; 
or  the  division  may  be  limited  to  one  of  these  parts.  And  in 
each  of  these  cases  the  cleft  presents  varieties.  Thus,  in  the  soft 
palate,  there  may  be  merely  a  division  of  the  uvula;  or  the  cleft 
may  extend  into  and  end  at  any  point  in  the  median  line  of  the 
soft  palate.     Cleft  of  the  soft  palate  occupies  a  median  position. 

In  the  bony  palate  the  fissure  may  be  unilateral,  bilateral  or 
median  in  site ;  and,  in  its  extent,  it  may  reach  partly  or  whollv 
through  the  osseous  vault.  There  is  fissure  in  which  the  cleft  in 
the  hard  palate  extends  partly,  or  wholly,  through  the  soft  palate; 
and  also  a  cleft  may  reach  through  the  soft  palate  and  penetrate 
the  osseous  vault  to  a  greater  or  less  distance. 

The  unilateral  osseous  fissure  is  normally  situated  on  the  left 
side;  and  when  incomplete,  it  occurs  in  varying  grades,  from  that 
in  which  the  alveolar  process  shows  a  slight  depression,  to  that 
in  which  the  cleft  reaches  nearly  through  the  vault.  The  uni- 
lateral fissure  begins  in  the  portion  of  the  alveolar  process  corre- 
sponding to  the  interval  between  the  outer  incisor  and  the  canine 
tooth.  And  when  the  cleft  is  reduced  to  its  minimum  form,  the 
only  traces  of  it  may  be  a  slight  depression  in  the  outer  face  of 
the  alveolar  process;  or  it  may  be  limited  to  imperfect  form,  or 
mal-position  of  the  two  corresponding  teeth.  The  unilateral 
cleft,  when  it  is  extensive,  is  not  confined  to  the  side  of  the  vault; 
in  the  soft  palate  the  breach  occupies  the  median  line. 

The  bilateral  fissure  may  only  implicate  a  part  of  the  palatal 
roof;  or  it  may  traverse  the  entire  extent  of  the  palatal  structures. 
In  the  bilateral  cleft,  which,  from  the  osseous  structures  which  it 
divides,  might  be  well  named  alveolo-palatal  cleft,  the  united 
fissures  resemble  the  letter  Y,  between  the  anterior  branches  of 
which  lies  the  premaxillary  bone.     The  premaxillary  bone  may 

(  659 ) 


OGO  PALATAL    (LEFT    OR    DIVISION. 

be  nearly  complete,  and  then  contain  three  or  four  teeth;  or  it 
may  be  reduced  to  a  rudimentary  fragment;  and  finally,  in  the 
worst  cases,  the  bone  may  be  wanting  and  the  Y-gap  then 
assumes  the  sliape  of  a  broad  I.  The  double-fissured  cleft  may 
be  incomplete,  posteriorly 

As  rarer  complications,  there  may  coexist  a  cleft  in  the  bony 
palate,  and  also  one  in  tlie  soft  palate;  and  the  two  are  separated 
by  a  bridge  of  normal  tissue.  An  osseous  palatal  cleft  is  usually 
associated  with  labial  cleft;  and  the  extent  and  gravity  of  the  one 
lias  its  correlate  in  the  extent  and  gravity  of  the  other,  arising 
from  similar  causes;  and  the  labial  and  palatal  clefts  often  have 
many  points  in  common. 

The  cleft  in  the  soft  palate  is  of  V-form  with  apex  in  front. 
The  base  of  the  gap,  when  the  parts  are  most  widely  separated, 
nearly  equals  the  breadth  of  the  soft  palate;  and  the  author  has 
observed  that  the  absence  of  tissue  is  often  greater  on  one  side 
than  on  the  other.  The  tissue  composing  the  sides  may  be  of 
web-like  thinness;  or  it  may  be  of  the  usual  thickness  of  the  nor- 
mal palatal  reil ;  conditions  which  have  a  bearing  on  the  success 
or  failure  of  work  undertaken  for  the  closure  of  palatal  cleft. 

Besides  the  forms  of  cleft  which  have  been  described,  there 
has  been  observed  one  which  has  a  median  position,  since  it  lies 
in  the  anterior  part  of  the  sutural  line  of  the  superior  maxilla. 
This  is  a  mild  form  of  malformation,  since  it  lies  merely  between 
the  middle  incisor  teeth  and  does  not  reach  further  back  than 
the  anterior  palatine  foramen.  This  median  fissure  may  be 
associated  with  unilateral  or  bilateral  cleft. 

The  osseous  palatal  cleft,  whether  it  be  long  or  short,  may 
varv  much  in  its  breadth  ;  thus  the  two  sides  maybe  so  near  that 
the  mucous  membrane  of  one  side  loosely  touches  that  of  the 
other;  or  the  intervening  space  may  be  a  quarter  of  an  inch  or 
more  in  breadth.  The  overlying  nasal  septum  may  overliang 
the  vacant  space,  not  reaching  fully  to  the  level  of  the  adjacent 
palatal  processes;  or  the  septum  may  reach  to  and  be  attached  to 
one  of  the  lateral  palatal  processes. 

Besides  palatal  clefts  which  are  acts  of  nature  and  are  congen- 
ital, there  is  another  class  which  originates  from  disease,  acci- 
dental violence,  or  from  the  invasion  of  surgery  itself.  From 
syphilitic  or  tuberculous  disease,  the  soft  and  bony  structures  of 
the  palate  may  be  the  site  of  breach  or  opening;  also,  such  dis- 
ease in  parts  adjoining,  may  extend,  attack  and  open  the  palatal 
roof.     The   most   frequent  perforations   from   disease  are  those 


PALATAL    CLEFT    OR    DIVISION.  G61 

caused  by  constitutional  syphilis;  a  periosteal  or  subperiosteal 
oummy  growth,  situated  on  the  superior  or  inferior  face  of  the 
bony  vault,  may  destro}^  and  perforate  the  bone  and  soft  parts  : 
and  the  resulting  breach  will  be  greater  in  proportion  as  it  is 
situated  further  backwards;  for  the  palatal  processes  are  so  thick 
in  front  that  they  are  seldom  perforated  by  syphilitic  disease. 

The  soft  and  hard  palate  may  be  perforated  through  acci- 
dental agency;  and  these  clefts  ma}^  vary  as  greatly  in  site  and 
character  as  pjossibilities  are  permitted  within  the  scope  of 
chance;  among  such  agencies  may  be  mentioned  the  gunshot 
missile,  the  thrust  of  a  sharp-pointed  object,  etc.;  the  most  frequent 
is  that  in  which  the  subject  falls  and  thrusts  such  object  through 
the  palatal  structures. 

Perforation  can  arise  from  neoplasms  which,  arising  within 
tlie  nasal  fossge  or  the  maxillary  sinus,  at  length  come  in  contact 
with,  and  finally  pierce  through,  the  palatal  structures ;  and  in 
this  case  the  bony  arch  is  oftener  perforated  than  the  soft  palate; 
for  the  latter  wall  yield  and  recede  before  the  advancing  growth; 
and  perforation  can  only  occur  in  cases  in  which  the  tumor  is 
large,  and  the  pressure  has  been  long  continued. 

And  finally,  an  opening  may  be  made  through  the  palatal 
structures,  both  hard  and  soft,  as  a  pioneering  route  b}^  which 
tlie  surgeon  may  reach  growths  which  exist  within  the  nasal 
fossae.  This  operative  route  is  seldom  chosen,  since  the  resultant 
conditions  are  unfavorable  to  the  successful  closure  of  the 
opening  in  the  palatal  structures;  and  as  the  cleft  remaining 
would  entail  much  functional  impairment,  the  surgeon,  if  possi- 
ble, should  avoid  forming  such  breach. 

Whetlier  the  palatal  cleft  be  of  ante-natal  or  subsequent 
origin,,  it  is  the  source  of  much  inconvenience  to  its  possessor; 
even  in  slight  grades  of  palatal  cleft  this  is  true.  Integrity  of  the 
palatal  structures  is  necessary  for  the  proper  accomplishment  of 
suction,  for  tlie  retention  of  food  in  the  buccal  cavity  in  the  act 
of  chewing,  and  thirdly,  for  well-regulated  deglutition ;  also  a 
perfectly  formed  palate  is  requisite  for  articulate  speech  and 
modulated  voice ;  and  its  absence  interferes  with  smell  and 
taste. 

The  interference  with  the  act  of  suction  seriously  obstructs 
the  nutrition  of  the  infant  which  is  the  subject  of  such  mal- 
formation ;  in  such  an  infant,  the  chances  of  living,  or  of  reaching 
physical  maturity,  are  much  lessened.  And  when  food  is  to  be 
masticated,  the  escape  of  a  portion  of  the  aliment  into  the  nasal 


GG2  palatal  cleft  or  division. 

passages  causes  much  annoyance.  And,  conversely,  the  broken 
partition  between  the  buccal  and  liasal  cavities  permits  the 
escape  into  the  latter  of  the  nasal  and  catarrhal  excreta,  of  "wliich 
the  absence  of  suction  prevents  the  normal  dislodgment  and 
elimination.  Deglutition  is  faultily  accomplished.  Entrance 
into  both  the  nasal  and  the  air-passages  is  but  imperfectly  guarded 
against,  and  pulmonary  affection  might  arise  from  nutrient 
material  which  has  lost  its  way. 

The  functional  impairments  cited  are  slight  when  compared 
with  those  of  phonation  and  articulation,  for  the  patient  has  tlic 
privilege  of  concealment  in  regard  to  the  former  defects,  but  in 
resj^ect  to  his  voice,  every  word  he  utters  reveals  his  defect,  and 
tells  the  story  of  his  malformation.  Tlie  hollow  nasal  tone  of 
his  vowel  sounds,  and  the  ill  molding  and  tripping  utterance  of 
his  palatal  consonants,  are  more  disagreeable  to  the  subject's 
ears  than  to  those  of  his  listener.  That  this  is  but  a  feeble 
glimpse  of  the  subjective  side  of  cleft  palate  is  more  than  con- 
firmed by  the  appeals  for  relief  on  the  part  of  victims  of  such 
deformity.  If  the  patient  be  an  adult,  as  has  been  the  case  in 
some  treated  by  the  writer,  his  api)eal  for  relief,  though  in  words 
deformed  in  tone,  accent  and  articulation,  is  eloquent  enough  to 
enlist  in  his  behalf  both  the  heart  and  hand  of  the  surgeon.  In 
such  a  case,  Roux,  the  pioneer  surgeon  in  this  work,  has  recorded 
his  experience  in  touching  lines. 

Before  describing  the  means  which  may  be  used  for  the  relief 
of  cleft  palate,  a  brief  reference  will  be  made  to  the  causation  of 
the  deformity.  The  origin  of  congenital  cleft  palate,  like  that  of 
labial  cleft,  is  referred  to  an  imperfect  development  of  the  primi- 
tive elements  of  the  embryonic  face.  At  the  fifteenth  day  of 
feetal  life,  as  before  stated,  there  are  to  be  found  three  parts  which 
are  destined  to  form  the  future  face,  viz.,  a  superior  or  frontal 
plate,  and  on  each  side  of  this  a  labial  or  mandibular  plate;  this 
lateral  plate  or  process  is  first  single;  later  it  divides  into  two 
parts,  of  which  the  lower  branch  uniting  with  a  similar  portion 
from  the  opposite  side,  becomes  the  lower  jaw  and  the  lower  lip; 
but  the  upper  part  of  the  lateral  bifid 'plate,  destined  to  form  the 
upper  jaw,  does  not  fuse  with  its  opposite  fellow.  About  the 
twentieth  day,  there  are  seen  two  processes  proceeding  from 
the  frontal  i)late,  which,  descending,  form  the  incisive,  or  pre- 
maxillary  bones.  And  soon  afterwards,  there  springs  from  the 
frontal  [)late  a  process  which  is  the  future  vomer,  or  sej)tum 
separating  the  nostrils;  and  this  vertical  process  is  met  by  two 


PALATAL    CLEFT    OR   DIVISION.  G6o 

horizontal  plates  from  the  superior  maxilla,  wliicli  become  the 
palatal  plates,  and  separate  the  buccal  from  the  nasal  cavities. 
Continuous  posteriorly  with  these  horizontal  palatal  processes, 
there  is  developed  the  soft  palatal  veil.  Soon  afterwards,  ossifi- 
cation of  the  future  upper  jaw  commences  by  four  ossific  centres: 
one  for  the  malar  portion,  one  for  the  palatal,  one  for  the 
canine,  and  one  or  two  for  the  incisive  portion.  Of  these 
four  portions  the  incisive  is  tlie  one  which  has  been  specially 
observed,  on  account  of  its  bearing  on  hare-lip  and  cleft  palate; 
this  incisive  portion  uniting  with  its  fellow  of  the  opposite  jaw, 
there  is  formed  the  premaxillary,  sometimes  called  the  inter- 
maxillary bone.  This  bone  occupies  the  triangular  space  of 
which  the  apex  is  at  the  anterior  j)alatine  foramen,  and  the  base 
forms  the  median  section  of  the  alveolar  process.  The  origin  of 
cleft  in  these  structures  is  thought  to  occur  as  follows:  Let  there 
be  an  arrest  of  development  of  the  canine  piece  and  the  inter- 
maxillary bone,  and  unilateral  fissure  will  result;  and  let  there 
be  such  arrest  on  each  side,  and  bilateral  cleft  will  arise.  And, 
again,  let  the  development  of  the  horizontal  palatal  processes  be 
checked,  and  a  fissure  will  remain  between  these  parts;  and  such 
fissure  may  be  a  continuation  of  the  anterior  unilateral,  or 
bilateral  fissure. 

The  causes  which  have  been  assigned  for  the  arrest  of  devel- 
opment of  the  palatal  and  alveolar  structures  lie  rather  in  the 
domain  of  plausible  theory  and  conjecture,  than  within  the 
range  of  ascertained  facts;  they  remain  as  problems  to  be  solved 
by  the  future  teratologist. 

As  has  been  stated  in  respect  to  the  labial  cleft,  so  in  the 
case  of  the  palatal  cleft,  it  seems  that  the  causes  which  led  to 
arrest  of  fusion  may  be  suspended,  and  the  parts  may  resume 
their  normal  growth,  and  proceed  to  perfect  development;  that 
is,  a  cleft  that  has  formed  in  intra-uterine  life  may  close  before 
birth.  And  continuing  the  comparison  with  the  lip,  as  in  the 
latter  a  cleft  may  close  after  birth,  so  a  palatal  cleft  may  vanish 
through  late  closure.  Trelat  saw  a  man  in  whom  a  congenital 
palatal  cleft  had  closed  when  he  w^as  twelve  years  of  age.  Yet 
intra-uterine  as  well  as  post-natal  spontaneous  closure  is  a  rare 
event;  and  the  hope  of  relief  in  this  wise  is  so  seldom  realized, 
that  if  it  be  indulged  in  by  the  parent  and  physician  they  may, 
like  (Esop's  traveler,  wait  long  on  the  river's  bank  expecting  its 
waters  to  run  away. 

Treatment. — The  methods  which  may  be  resorted  to  for  relief 


CG4  I'ALATAL    CLEFT    Oli    DIVISION. 

in  cleft  palate  are  mechanical  and  operative.  The  mechanical 
method  consists  in  ilie  employment  of  an  obturator  by  means  of 
which  the  opening  is  occluded.  Such  obturators,  in  manifold 
forms,  have  been  constructed  b\'  those  who  have  given  stud}''  to 
this  subject.  The  difficulty  encountered  in  this  work  is  in  that 
part  of  the  device  which  is  destined  to  maintain  the  obturator  in 
site.  This  has  been  attempted  by  wing-like  or  arm-like  processes, 
which  pass  into  the  superjacent  nasal  passages,  and  thus  hold  in 
suspension  the  occluding  part.  Or  the  suspension  may  be  done 
by  lateral  springs  which  rest  in  the  nasal  passages.  The  fixation 
may  also  bo  effected  by  the  aid  of  hooks  and  clasps,  which  are 
attached  to  the  teeth  or  alveolar  processes.  In  case  of  a  rounded 
or  oval  brench,  the  closure  has  been  accompli.shed  by  means  of  a 
device  similar  to  a  double  button,  and  which  resembles  the 
modern  sleeve-button. 

These  obturators  are  constructed  of  India  rubber  or  gold;  also, 
for  this  purpo.'je  aluminium  might  be  used  ;  and  this  metal  com- 
mends itself  by  its  lightness.  An  important  requisite  which 
these  contrivances  should  possess,  is  that  they  should  be  securely 
fastened  in  their  position,  and  thus  the  bearer  secured  from  all 
peril  of  swallowing  them.  The  unending  task  of  caring  for 
such  device  is  a  serious  objection  to  it;  hence,  the  aid  of  surgery 
is  often  sought  by  the  unfortunate  subject  of  palatal  cleft. 

Inasmuch  as  the  work  of  closing  the  breach  in  the  soft  and 
in  the  osseous  structures  is  different,  it  will  be  more  convenient 
to  treat  of  each  separatel}',  and,  thus  proceeding,  the  closure  of 
cleft  in  the  soft  palate  will  first  be  considered. 

The  pioneer  in  the  closure  of  cleft  palate  by  operative  means 
was  Roux,  who  performed  his  first  operations  in  1819,  and  he 
thought,  at  the  time,  that  he  was  the  first  one  to  do  the  operation; 
this,  however,  was  an  error,  since  he  had  been  preceded  by  the 
elder  Graefe,  whose  operation,  though  a  failure,  was  done  in  181G. 
The  method  of  Roux  was  the  better  one,  and  was  so  acknowl- 
edged by  Graefe.  A  further  investigation  of  the  subject  has 
brought  to  light  the  fact,  that  the  operation  of  closing  tlie  soft 
palate  by  suture  w^as  proposed  to  the  French  Academy  in  1779 
by  Beziers.  Priority  here,  as  elsewhere,  has  proved  a  Protean 
entity,  a  flitting  fugitive,  which,  though  sought  and  temporarily 
possessed  by  rival  claimants,  has  in  the  end  escaped  their  grasp 
and  fled  to  other  hands.  Such  emulation,  however,  should  be 
commended,  since  it  is  of  generous  source  and  is  in.spired  by 
justice  to  give  the  palm  to  him  who  has  earned   it.     Gold   too 


STAPHYLOREAPHY.  665 

often  finds  its  way  to  tlie  hand  of  him  who  has  not  earned  it; 
ilie  curators,  by  which  tlie  field  of  science  is  vigilantly  guarded, 
do  not  permit  such  wrong;  the  earner  is  secured  in  his  earnings, 
often  through  the  mutual  aid  of  his  competitors. 

Staphylorraphy,  which  signifies  sutural  closure  of  the  soft 
palate,  was  a  na;me  invented  and  given  by  Roux  to  this  opera- 
tion. As  a  surgical  procedure  it  is  tedious,  delicate,  and  for  suc- 
cessful termination,  it  demands  some  degree  of  experience:  the 
first  essay  of  the  operator  is  commonly  a  partial  or  complete 
failure. 

Before  describing  this  operation,  it  is  proper  to  advert  to  cer- 
tain procedures  in  which  closure  has  been  attempted,  and  some- 
times attained  by  plans  which  may  be  called  non-operative. 
Among  these  may  be  mentioned  the  plan  of  cauterization,  wdiich 
was  practiced  by  Cloquet.  Observing  that  contraction  followed 
burns,  in  1855,  Clocj^uet  counseled  to  use  this  means  for  the  clos- 
ure of  palatal  and  labial  clefts  in  subjects  who  are  unfit  for 
plastic  operation.  Cloquet  does  not  cauterize  the  entire  cleft  but 
only  the  angular  end  of  the  same:  and  this  being  repeated  a 
number  of  times,  the  efifect  is  similar  to  a  number  of  sutures.  In 
this  way,  as  early  as  1826,  Cloquet  cured,  by  means  of  twenty 
cauterizations,  a  palatal  cleft  which  had  arisen  from  constitu- 
tional syphilis.  Afterwards,  in  another  case,  in  which  the  cleft, 
having  been  closed  by  sutures,  reopened,  the  opening  was  closed 
by  rej)eated  cauterizations.  In  this  manner,  a  palatal  cleft  of 
traumatic  origin  was  closed  by  Ndlaton.  The  objection  to  tins 
method  is  that  it  requires  so  long  a  time;  but  the  advantages 
claimed  for  it  by  Cloquet  are  that  it  is  attended  by  slight  pain, 
and  the  patient,  during  treatment,  need  not  suspend  his  business. 
To  do  the  work,  the  galvanic  cautery,  the  hot  iron  or  the  poten- 
tial cautery  may  be  used.  Cloquet  employed  the  nitrate  of  mer- 
cury. Some  years  ago,  this  plan  was  used  by  the  author  to  com- 
plete closure  in  a  case  of  cleft  palate  in  which  sutural  closure  had 
been  but  partially  successful;  the  ferrum  candens  was  employed, 
and  the  cauterization  repeated  a  number  of  times,  at  intervals  of 
two  or  three  days;  thus  proceeding,  the  breach  was  lessened  but 
not  wholly  closed.  It  is  important  in  this  work  to  cauterize  onh^ 
the  angular  end  of  the  cleft. 

Spessa,  in  1844,  announced  that  he  had  cured  cleft  palate  by 
simply  paring  the  edges  of  the  opening,  and  then  repeating  this 
every  fifteen  or  twenty  days;  and  Spessa  advises  that  the  same 
be  done  to  close  hare-lip  or  vesico-vaginal  fistula. 
43 


660  PALATAL    CLEFT    OR    DIVISION. 

Near  the  same  time,  Dieffenbacli  advised  to  close  small 
clefts  by  applying  to  the  margins  of  the  breach  the  tincture  of 
cantharides;  and  this  should  be  repeated  as  soon  as  the  vesicated 
surface  has  healed.  Other  surgeons  report  closure  in  this  way; 
and  it  seems  that  it  was  chiefly  resorted  to  in  cases  in  which  an 
operation  to  etfect  closure  had  not  been  wholly  successful. 

Staphylorraphy  is  an  operation  for  the  closure  of  a  palatal 
cleft  which  is  limited  to  the  soft  palate;  and  the  work  would  be 
of  a  very  simple  order,  were  it  not  for  the  almost  unapproacha])le 
site  of  the  parts  which  are  to  be  operated  on.  The  operation,  in 
its  simplest  form,  consists  merely  in  trimming  the  opj)osite  bor- 
ders of  the  opening,  and  then  coaptating  and  holding  these 
together  by  suitable  sutures:  surgical  acts  so  simple,  if  the  breach 
were  on  the  outside  of  the  body,  that  they  would  not  deserve 
mention,  much  less  would  they  merit  a  special  name.  But  this 
breach  lies  in  the  inmost  recess  of  the  alimentary  vestibule,  to 
which  light  has  not  ready  ingress;  the  fragmentary  structures 
are  well  supplied  with  sentient  and  motor  nerves,  so  that  when 
touched  on  either  their  buccal  or  nasal  side,  they  are  thrown 
into  spasmodic  contraction,  which  may  be  propagated  downwards 
to  the  stomach,  and  provoke  vomiting;  and  finally,  an  almost 
insuperable  difficulty  may  be  encountered  in  the  scantiness  of  the 
structures;  too  short,  in  fact,  to  form  a  complete  bridge  across  the 
gap.  Hence,  the  energies  of  mechanical  invention  have  been 
stimulated  to  devise  means  to  overcome  these  obstacles;  and 
among  these  aids  may  be  mentioned  gags,  tongue  depressors, 
palatal  supporters,  specially  contrived  needles,  needle-holders, 
sutures,  suture-clasps  and  sponge-holders.  Myotomy  and  lat- 
eral incisions  have  been  made  tributary  allies  in  this  surgical 
work. 

An  important  preliminary  is  to  so  discipline  the  jtalatal  and 
pharyngeal  structures  that  they  will  yield  quiet  obedience  to  the 
attacks  made  on  them.  The  reflex  sentinel  who  awakens  these 
parts  to  their  destined  automatic  action,  must  be  made  to  tempora- 
rily sleep  on  his  post;  and  this  is  done  by  so  multiplying  the 
movements  of  the  parts  that  they  finally  cease  to  act.  This  is 
brought  about  by  often  touching  the  parts  with  some  irritating 
object.  The  adult  may  do  this  himself,  but  if  the  patient  be  a 
child,  the  parent  or  nurse  can  do  it.  As  instrument  for  this  irri- 
tation, two  or  three  stiff  feathers  may  be  tied  together,  and  the 
plumed  end  employed;  or  the  work  can  be  done  very  successfully 
with  a  small  tooth-brush.     If  such  preliminary  training  be  dili- 


STAPHYLORRAPHY.  667 

gently  continued  for  a  couple  of  days,  the  reflex  movement  will 
be  so  subdued  that  it  will  not  interfere  with  the  operation. 
■Jb  Though  the  cleft  may  quite  divide  the  soft  palate,  yet  some- 
times there  is  an  amplitude  of  tissue  to  quite  close  the  gap,  with- 
out tension.  In  these  cases,  in  the  act  of  swallowing,  the  two 
sides  approach  and  touch  each  other.  Such  was  the  character  of 
a  cleft  in  a  young  Canadian  physician,  who  applied  to  Roux  in 
1819  for  treatment  of  his  real  formation;  the  operation  was  a 
successful  one,  and  Roux  added  another  name  to  surgical  nomen- 
clature by  naming  the  work  done,  staphylorraphy.  And  it  is  in 
cases  of  this  character  that  the  operation  promises  the  best 
results. 

When  should  the  closure  of  congenital  palatal  cleft  be  done? 
A  citation  of  the  opinions  given  in  answer  to  this  question  would 
burden  the  reader  with  confusing  differences;  some  would  do  the 
operation  when  the  child  is  a  month  old.  Ehrmann  operated* 
when  the  child  was  five  months  of  age;  some  would  do  it  any 
time  during  the  first  year  of  life  ;  Bihroth  and  Owen  would  oper- 
ate when  the  child  is  three  or  four  years  old;  Trelat  operates 
after  the  subject  has  reached  puberty.  Hence  the  surgeon 
finds  authority  which  sanctions  the  operation  at  any  age. 
The  mortality  which  has  followed  the  work  done  on  young 
infants  shows  that  early  operations  are  very  fatal.  The  condi- 
tion of  the  cliild's  health  should  be  considered  quite  as  much  as 
its  age.  This  rule  was  enjoined  by  Thos.  Smith,  who  states  that 
in  a  series  of  fifty  infants  which  were  brought  to  him  for  opera- 
tion, he  selected  not  more  than  one  in  eight  of  the  number.  This 
is  an  important  rule  to  be  observed,  not  only  in  the  operation  for 
cleft  palate,  but  in  all  other  surgical  operations  on  infants;  the 
feeble,  sickl}^,  emaciated  and  ill-nourished  infant  will  generally 
succumb  to  the  surgeon's  knife;  to  such  should  be  accorded  the 
right  which  Dupuytren  chose  foi  himself,  when,  in  declining  an 
operation  for  empyema,  he  said  that  he  "  preferred  to  die  by  the 
hand  of  God  rather  than  by  that  of  the  surgeon."  The  child, 
however,  which  is  in  robust  health,  will  readily  bear  the  opera- 
tion, even  though  it  be  done  in  the  early  months  of  life,  and  this 
vigorous  health,  rather  than  months  or  years,  best  indicates  the 
period  suited  for  the  operation.  Staphylorraphy  is  extremely 
difficult  to  do  in  the  infant,  in  consequence  of  the  small  space  in 
which  instruments  must  be  used. 

As  instruments  there  are  required  a  mouth -gag,  a  knife  or  scis- 
sors for  trimming,  clasp-forceps  to  catch  and  hold  the  margins  of 


668  I'ALATAL    CLKFT    OR    DIVISION. 

the  cleft,  sharp,  strong,  curved  needles  and  a  needle-holder,  tine 
gilded  or  plated  copper  wire  for  suture,  small  sponges  and  sponge- 
holders,  and  ice  water. 

As  gag  or  instrument  to  retain  the  mouth  open,  that  of  Smith 
is  most  commonly  used.  This  depresses  the  lower  jaw  and 
tongue,  and  retains  the  mouth  well  open.  It  does,  however,  more 
than  this,  it  forces  the  tongue  backwards;  and  this  is  a  serious 
defect  of  the  instrument :  so  much  so  that  in  using  it,  the  author 
has  been  compelled  to  attach  clasp-forceps  to  the  tongue,  and 
thus  draw  the  latter  forwards  during  tlie  work.  And  to  avoid 
this,  the  writer  would  use  the  interdental  gag,  which  has  already 
been  mentioned  in  the  chapter  treating  of  excision  of  the  tongue. 
The  wedge-shaped  portion  of  this  gag  has  a  hollow  face  above 
and  below,  so  that  it  can  be  inserted  between  the  upper  and  lower 
jaws,  and  thus  the  mouth  is  retained  fully  open.  Anotlier  simi- 
•  lar  contrivance  is  one  in  which  to  the  inserted  wedge  is  fastened 
a  strap  which  ends  in  a  short  hook -shaped  retractor;  this  adjusta- 
ble strap  is  carried  behind  the  head,  and  the  retractor  hooked  in 
the  angle  of  the  mouth.  This  instrument  is  self-holding;  yet  it 
requires  attention,  lest  the  interdental  portion  slip  and  allow  the 
jaws  to  close.  Simon  of  Prague,  who  recommends  an  early 
operation  in  the  child,  sometimes  used  a  mouth-dilator  which  is 
always  accessible,  viz.,  the  finger  of  an  assistant,  which,  inserted 
into  the  mouth,  retained  the  latter  open.  The  writer  fears  that 
precept  here  was  not  illustrated  b}'^  example. 

A  scalpel  with  short  blade  and  a  long  handle,  or  long-handled 
scissors,  are  needed  to  trim  the  edges  of  the  cleft.  The  short 
blade  of  the  knife  should  have  a  straight  edge,  and  end  in  a 
sharp  point.  The  scalpel  is  better  than  the  bistoury.  Some 
operators  prefer  to  trim  with  scissors,  claiming  that  the  raw 
margin  can  thus  be  made  straighter  than  with  a  knife.  Long- 
handled  clasp-forceps  must  do  the  work  of  seizing  and  fixing  the 
free  border  in  the  work  of  trimming.  Short,  rounded  needles, 
with  moderate  curve,  are  needed  to  carry  the  sutural  material; 
also  a  needle-holder,  to  carry  the  armed  needle.  There  are  sev- 
eral patterns  of  this  instrument,  and,  in  its  stead,  one  may  use 
clasp-forceps  to  carry  the  needle.  Instead  of  the  needle  and 
holder,  the  two  may  be  combined  in  one  instrument,  consisting 
of  a  long  handle  and  curved  and  shaped  as  a  needle,  with  eye 
near  the  point.  The  handle  and  needle  portion  are  in  one  com- 
mon piece;  or  the  needle  portion  may  be  separable  from  the 
handle-bearing  part,  so  that  it  can  be  screwed  on,  and  unscrewed, 


STAPHYLORRAPHY.  669 

as  required.  Instead  of  this,  a  tubular  needle  is  used  by  some 
operators;  this  is  hollowed  through  the  handle  and  needle  por- 
tion, so  that  the  sutural  material  can  traverse  it,  and  be  protruded 
to  the  extent  which  is  needed.  The  hollow  needle  carries  wire. 
The  objection  to  this  instrument  is  tliat  the  needle  portion  must 
be  thicker  than  a  common  needle,  to  insure  against  breaking. 
Langenbeck  in  1860  announced  that  he  used  a  long-handled 
needle  which  w^as  fashioned  after  the  form  of  Bellocq's  naso- 
pharyngeal canula.  The  tubular  portion  had  a  sharp  needle- 
like end,  which  was  passed  through  the  edge  of  the  pared  margin, 
when  the  contained  spring  was  thrust  out,  and  the  thread 
fastened  to  this  and  drawn  through  t^ie  edge.  With  such  an 
instrument  Langenbeck  found  that  he  could  introduce  the  sutures 
with  great  rapidity.  A  fault  of  the  hollow  needle  is  that  it 
makes  an  orifice  much  larger  than  the  thread  or  wire  which  it 
conveys;  thus,  cutting  on  the  part  of  the  suture  is  favored. 

The  material  for  suture  may  be  wire,  silk  or  horsehair.  Silk 
is  less  used  than  formerly.  Though  horsehair  is  highly  advo- 
cated b}''  those  who  have  used  it,  yet  it  is  not  in  general  use.  Silver 
wire,  or  copper  wire  that  has  been  coated  with  silver  or  gold,  may 
be  employed.  Leaden  w^ire  was  used  in  the  early  palatal  opera- 
tions; it  soon  fell  into  disuse.  The  writer  prefers  gilded  copper 
wire,  since  it  is  stronger  than  pure  silver  wire,  and  hence,  finer 
thread  of  the  former  can  be  used.  The  difficulty  in  the  use  of 
silk  is  to  tie  it  closely,  so  as  to  hold  the  parts  in  contact.  Tying 
a  knot  in  the  bucco-pharyngeal  recess  is  not  easily  done.  But 
the  inserted  wire  may  be  closed  by  twisting  the  ends  together; 
and  the  final  tightening  may  be  done  with  clasp-forceps.  Or  the 
wire  may  be  closed  by  means  of  a  wire  twister;  an  instrument 
with  a  figure-of-eight  end.  The  sutural  closure  should  not  be  too 
tense,  lest  the  included  tissue  be  so  constricted  as  to  die;  and  then, 
though  union  of  the  sides  may  be  obtained,  small  openings  will 
be  left  at  the  site  of  the  sutures,  which  will  rec[uire  some  time  to 
heal. 

If  one  examines  the  history  of  staphylorraphy,  he  will  find 
described  many  more  instruments  which  have  been  devised  and 
used  in  the  work;  in  fact,  the  writer  has  mentioned  but  a  min- 
imum of  those  W'hich  have  been  invented;  yet  those  here 
described,  when  their  use  has  become  facile  through  experience, 
will  be  found  sufficient.  The  patient  who  has  fasted  for  eight 
hours  must  be  placed  in  a  recumbent  position,  with  the  shoulders 
somewhat  uplifted,  and  the  face  so  turned  backw'ards  that  when 


070  I'ALATAL    CI.KFT    OK    DIVISION. 

the  mouth  is  dilated  the  hght  will  fall  on  the  palatal  roof.  The 
patient  should  be  so  placed  that  the  light  can  enter  at  the  side  of 
the  operator,  rather  tluin  from  beliind.  To  illuminate  the  buccal 
cavity,  light,  artificial  or  solar,  may  be  reflected  into  the  cavity 
by  a  mirror  proi)erly  placed. 

Children,  and  also  adults,  should  be  anassthetized ;  only 
exceptionally  in  the  adult,  who  ])refers  to  be  a  witness  of  his 
operation,  may  this  rule  be  dispensed  with.  Yet  there  is  not 
unanimity  of  authority  on  this  point.  In  18G8,  in  the  lioyal 
Medico-Chirurgical  Society  this  subject  was  discussed  by  the 
members.  Smith  and  Annandale  advised  anaesthesia;  others 
opposed  it;  Prescott  Hevvett  reported  that  he  thus  lost  one  case. 
And  the  same  occurred  to  Langenbeck,  the  patient  dying  from 
the  blood  passing  into  the  air-passages.  And  in  another  patient, 
Langenbeck  barely  saved  life  by  performing  tracheotomy  and 
sucking  out  the  blood  that  had  escaped  into  the  bronchi.  Despite 
these  accidents,  the  custom  is  to  ancesthetize  the  patient,  and  with 
due  care  in  spraying  out  tlie  escaping  l)lood  with  sponges  which 
have  been  dipped  into  iced  water,  the  bleeding  will  be  controlled, 
and  but  little  blood  will  escape  downwards. 

The  mouth  being  retained  open  by  the  dilator,  the  surgeon 
seizes  the  margin  of  the  cleft  on  the  patient's  right  side,  near  the 
middle  of  the  border,  with  clasp -forceps,  and  holding  this  in  his 
left  hand,  and  having  drawn  so  as  to  make  the  part  tense,  he 
inserts  the  point  of  his  angular  knife  near  the  forceps  and  then 
trims  off  the  entire  border  upwards  and  downwards  from  the 
uvula  to  the  summit  of  the  cleft.  And  the  same  must  next  be 
done  on  the  remaining  side.  Particular  care  must  be  used  to 
trim  the  anterior  angle,  since  a  fragment  of  mucous  membrane 
remaining  would  obstruct  the  desired  closure.  The  lateral  trim- 
ming should  be  done  slopingly,  one  side  inclining  forwards  and 
the  other  backwards;  thus  done,  broader  and  congruent  marginal 
faces  are  formed,  adapted  for  union.  After  the  marginal  excision, 
the  remaining  raw  surface  will  broaden  through  the  retraction  of 
the  divided  mucous  membrane.  Such  retraction  may  be  due  to 
the  recoil  of  the  mucous  membrane  which  has  been  displaced 
towards  the  median  line,  by  the  traction  done  with  the  clasp- 
forceps.  In  place  of  grasping  the  margin  of  the  cleft,  the  uvula 
may  be  seized  with  forceps  and  the  parts  thus  drawn  in  any 
direction  most  convenient  to  do  the  trimming.  Instead  of  grasp- 
ing and  fixing  with  forceps,  Thiersch  and  Le  Fort  pass  threads 
through  the  parts  of  the- cleft  uvula;  and  these  threads  may  be 


STAPHYLOERAr^HY.  671 

held  by  an  assistant,  and  thus  each  side  can  be  drawn  on  as  is 
needed  in  the  work. 

In  tlie  marginal  trimming  the  operator  must  suspend  his 
work,  every  minute  or  two,  to  permit  the  assistant  to  sponge  out 
the  blood.  This  is  done  with  small  sponges  carried  by  special 
holders  or  clasp-forceps,  the  sponges  being  cleansed  and  cooled 
in  iced  water.  Thus  proceeding,  there  is  no  danger  of  much 
blood  entering  the  air-passages.  Though  these  interruptions 
prolong  the  operation,  they  secure  against  coughing  and  asphyxia. 
The  writer,  who  has  seen  palatal  closure  done  by  Sir  William 
Fergusson,  was  often  an  admiring  observer  of  the  tireless  patience 
of  this  veteran  surgeon;  not  unfrequently,  the  operation  occupied 
a  large  part  of  the  short  afternoon  of  winter  in  London ;  his 
standing  remark  to  his  class  was,  "Those  who  wait  to  the  end  of 
this  operation  deserve  a  premium."  Yet  it  was  this  patient  work 
that  enabled  Fergusson  in  1885  to  record  fifty-six  operations  with 
but  two  failures. 

In  the  case  here  supposed,  in  which  tlie  sides  can  easily  be 
united  without  lateral  incisions,  or  division  of  the  palatal  mus- 
cles, the  operator  next  proceeds  to  the  introduction  of  the  sutures; 
and,  as  already  mentioned,  these  may  be  passed  with  a  long- 
handled  needle,  or  with  short  curved  needles,  carried  by  a 
holder.  The  operator  will  do  well  to  learn  each  of  these  ways, 
since  one  is  sometimes  more  convenient  than  the  otlier.  To  use 
•  the  long-liandled  needle,  of  which  the  eye  is  near  its  point,  let 
the  wire  enter  the  eye  on  the  curved  side  of  the  needle;  for  if 
thus  inserted,  after  the  needle  has  carried  the  wire  through  the 
margin,  the  wire  can  be  caught  with  a  tenaculum,  and  withdrawn 
from  tlie  needle.  But  if  the  wire  be  passed  through  from  the 
convex  side,  then  its  extraction  from  the  needle  will  be  much 
more  difficult,  since  after  passing  through  the  tissues,  it  will  lie 
on  the  side  of  the  needle  farthest  from  the  operator. 

The  needles  which  are  carried  by  a  holder  should  be  round 
and  of  annealed  metal;  if  more  fragile  needles  are  used,  they  may 
break  in  being  forced  through  the  palatal  structure.  The  wire 
used  should  be  at  least  two  feet  long,  it  should  have  a  needle  on 
each  end,  and  after  being  passed  through  the  needle,  the  wire 
should  be  so  twisted  that  it  cannot  escape  from  the  needle's  eye 
during  the  passage.  Some  practice  is  needed  to  grasp  the  needle 
■with  the  holder  in  such  a  way  that  the  former  can  be  made  to 
pass  properly  througli  the  margin;  to  do  so,  let  the  needle  be 
grasped  so  as  to  form  an  acute  angle  with  the  holder;  and  thus 


072  PALATAL    CLEFT    OR    DIVISION. 

held,  let  it  be  passed  from  the  nasal  side,  and  emerge  on  the 
buccal  face;  and  then  the  needle  on  the  other  end  of  the  wire 
must  be  passed  through  the  oj)posite  margin.  The  two  needles 
being  removed,  the  ends  of  the  wire  are  carried  over  the  patient's 
head,  and  temporarily  twisted  together.  This  first  suture  should 
lie  near  the  anterior  angle  of  the  cleft;  and  it  is  the  most  difficult 
one  to  place.  The  remaining  sutures  are  to  be  passed  in  a  similar 
manner,  at  intervals  of  a  quarter  of  an  incli,  from  the  anterior 
portion  of  the  breach  to  its  uvular  ending;  that  is,  the  work 
should  proceed  from  before,  backwards.  Tliree  or  four  sutures 
are  commonly  sufficient  to  effect  the  closure  of  a  cleft  which 
traverses  the  entire  soft  palate.  The  wires  are  next  to  be  closed 
in  the  order  in  which  they  were  introduced  from  before  back- 
wards; the  closure  being  best  done  with  a  wire  twister.  This 
closure  should  fully  coaptate  the  two  sides,  which,  in  the  case 
under  consideration,  contain  material  enough  to  unite  without 
tension.  And  the  sutures  being  closed,  tlie  wire  is  to  be  severed, 
and  the  ends  of  the  suture  bent  to  one  side,  so  that  they  will  lie 
close  in  contact  witli  tlie  wall  above.  If  there  be  observed  gai)ing 
between  the  sutures,  this  may  be  closed  by  a  more  superficial 
suture,  which  is  inserted  by  means  of  a  needle  that  is  much 
curved,  and  made  to  traverse  and  include  both  sides. 

The  operation  being  done,  the  patient  should  be  placed  in 
bed  and  remain  quiet  for  a  few  days.  The  food  used  should  be 
liquid,  or  such  as  can  be  swallowed  with  the  least  efibrt.  The 
buccal  cavity  should  be  cleansed  every  few  hours;  and  for  this 
purpose  mint- water  may  be  employed;  the  patient  if  intelligent 
may  do  this  himself.  No  effort  of  gargling  must  be  made.  The 
work  of  cleansing  may  be  done  by  means  of  a  syphon-like  irri- 
gator, by  which  a  fine  stream  of  fluid  may  be  brought  into  the 
various  recesses  of  the  buccal  cavity.  In  ciiildren,  irrigation  is 
the  most  convenient  way  of  doing  this  work.  Speech  is  to  be 
restricted  to  whispering;  and  this  limited  to  the  words,  yes  and  no. 

In  respect  to  the  time  when  the  sutures  should  be  removed, 
authorities  differ,  the  time  given  varying  from  four  to  ten  days. 
From  the  writer's  experience,  sutures  should  remain  longer  in  the 
child  tlian  in  the  adult;  in  adults,  the  removal  can  usually  com- 
mence on  the  fifth  day,  when  every  second  one  may  be  with- 
drawn, the  work  beginning  with  the  second  one  from  the  uvular 
portion;  the  remaining  sutures  may  be  removed  about  the  tenth 
day.  In  children,  the  writer  leaves  some  of  the  sutures  a  much 
longer  period ;  and  none  should  be  removed  before  a  week  has 


STAPHYLOREAPHY.  673 

elapsed.  If  the  child  be  refractory,  care  must  be  taken  lest,  in 
the  act  of  withdrawal  of  the  wire,  some  restive  movement  may 
tear  apart  the  united  edges;  but  if  a  long  time  has  elapsed,  then 
the  union  has  probably  become  so  firm  that  there  is  little  peril  of 
separation.  In  a  few  instances,  the  writer  has  allowed  some  of 
the  sutures  to  remain  in  place  for  a  month;  in  one  case  they 
remained  a  still  longer  period.  Sutures  permitted  to  remain  a 
long  time,  should  be  cut  short.  Sutures  which  are  thus  allowed 
to  remain,  by  their  presence  excite  some  irritation,  which  lessens, 
and  tends  to  close  the  separated  spaces.  To  remove  the  suture 
seize  it  by  the  twisted  portion,  divide  the  wire  on  one  side  of  the 
twist,  and  then,  drawing  on  the  latter,  the  wire  will  easily  be 
withdrawn. 

The  sutural  union  as  above  described,  suffices  for  all  cases  in 
which  there  is  an  amplitude  of  tissue ;  frequently,  however,  the 
structures  are  so  defective  that,  after  being  pared,  they  cannot  be 
juxtaposed;  or,  if  it  be  possible  to  unite  them,  the  parts  are  so 
tense  that  the  soft  jDalate  cannot  perform  its  normal  functians  in 
the  acts  of  swallowing  and  speaking;  for  iu  such  tense  state,  in 
deglutition,  the  materials  can  enter  the  choan«;  and  in  speaking, 
the  tone  of  the  voice  is  nasal  in  character.  Hence,  to  lessen  these 
functional  defects,  certain  collateral  stej)s  or  procedures  are  some- 
times resorted  to;  and  these  may  precede,  accompany  or  follow 
the  sutural  closure. 

To  avoid  or  lessen  tension,  Sedillot,  who  has  studied  this 
matter,  finds  tliat  it  has  been  done  in  one  of  the  following  ways: 

1.  Lateral   incisions   were   made   by   Dieffenbach    and    Liston. 

2.  Mettauer,  of  Virginia,  made  four  semilunar  cuts,  six  lines  long, 
curved  externally,  on  each  side  of  the  palatal  opening.  3.  "Warren 
divided  the  anterior  pharyngeal  arches;  others,  however,  divide 
the  posterior  pillars.  4.  Fergusson  divided  the  muscles  above 
the  soft  palate,  viz.,  he  severed  the  levator  and  tensor  palati 
muscles,  and  this  was  done  by  a  knee-shaped  knife,  which  is 
passed  above  the  palatal  veil,  and  caused  to  cut  from  above 
downwards  on  each  side;  and  when  this  is  done,  the  soft  palate 
remains  motionless.  In  this  section,  Fergusson  left  the  surface  of 
the  soft  palate  intact.  Sedillot  favors  a  combination  of  the 
methods  of  Fergusson  and  AVarren ;  after  such  section,  one  is 
surprised  at  how  much  the  existing  breach  is  narrowed.  Sddillot 
advises  that  the  division  of  the  muscles  precede  the  trimming  of 
the  borders. 

Smyly  divided  the  muscles  on  the  nasal  side  of  the  soft  palate; 


674  PALATAL    CLEFT    OR    DIVISION. 

his  method,  announced  in  1862,  was  to  pass  a  long-handled  knife 
along  the  floor  of  the  nostril,  the  blade  resting  at  the  hamular 
process  of  the  pterygoid  i)late;  then,  while  the  finger  presses  up 
the  soft  palate  from  below,  the  knife  divides  all  the  muscular 
fibres  which  act  on  the  soft  palate. 

Instead  of  severing  the  palatal  muscles.  Gay,  in  1852,  loosened 
and  dissected  up  the  soft  palate  from  the  bony  palate. 

To  quiet  the  palatal  muscles.  Pitha  made  an  incision  in  the 
soft  palate  itself;  this  he  did  by  inserting  the  knife  near  the  ham- 
ular process,  and  cutting  thence  forwards  and  inwards,  until  he 
reached  the  long  arch. 

Besides  these  adjuvant  incisions  of  the  arches,  and  division  of 
the  palatal  mu.scles,  if  sufficient  laxity  of  parts  is  not  obtained, 
one  may  make  lateral  longitudinal  incisions  through  the  sides  of 
the  soft  palate,  near  the  lateral  attachment  of  the  soft  palate;  such 
incision  was  done  by  Sedillot,and  many  other  0})erators;  and  the 
Avriter  may  add  that  it  is  his  custom  to  make  such  lateral  incis- 
ions in  nearly  all  cases.  These  cuts,  one  or  two,  may  be  made  on 
each  side,  and  tliey  may  reach  quite  through  the  velum;  or,  as 
Friedinger  advises,  these  lateral  cuts  may  reach  but  partially 
through.  To  maintain  these  cuts  open  when  they  reach  through 
the  velum,  tiie  writer  and  others  have  inserted  in  them  plugs  of 
lint,  which  were  allowed  to  remain  in  place  for  a  few  days.  To 
relieve  tension,  one  or  more  of  tlie  plans  mentioned  may  be 
employed;  but  to  correct  the  defects  in  phonation  which  are 
often  found  to  remain  after  the  operation  of  staphylorraphy, 
certain  corrective  procedures  have  been  advised;  but  before 
describing  these,  the  nature  and  cause  of  the  vocal  defect  should 
be  treated  of. 

According  to  the  studies  of  Czermak  in  this  field,  speech  of 
normal  sound  demands  a  temporary  closure  or  separation  of  the 
nasal  passages  from  the  bucco-pharyngeal  cavity;  and  this  closure 
is  done  by  the  soft  palate.  During  the  production  of  nearly  all 
the  articulate  sounds,  the  choante  must  be  shut ;  in  the  formation 
only  of  the  nasal  sounds,  m,  n  and  no,  must  the  choanse  remain 
open.  The  remaining  sounds,  both  vowels  and  consonants, 
require  for  normal  expression  the  complete  closure  of  the  choanse; 
and  if  such  closure  does  not  exist,  all  the  sounds  are  of  nasal 
character.  And  this  is  most  apparent  in  the  sounding  of  the 
labial,  lingual  and  palatal  consonants.  And  in  case  of  extensive 
labial  clefts,  the  sounds  of  e,  g  and  z  cannot  be  correctly  formed; 
r  is  changed  to  erl;  p,  q  and  t  lose  their  sharpness,  while   the 


STAPHYLORRAPHY.  675 

vowels  are  not  pronounced  clearly  and  distinctly.  And  if  there 
be  a  cleft  through  the  hard  palate,  this  interferes  more  with 
articulate  speech  than  does  a  cleft  through  the  soft  one.  The 
subjects  of  such  defect  become  timid  and  prefer  silence  to  speech; 
their  language  is  limited  and  monosyllabic. 

The  closure  of  the  cleft  in  the  soft  palate  where  the  defect  has 
been  limited  to  that  part,  has  often  disappointed  both  the  patient 
and  the  surgeon;  in  fact,  this  disappointment  has  sometimes 
been  so  great  that  the  patient  has  asked  to  have  the  closed  parts 
reopened. 

In  order  to  improve  phonation  Billroth  operated  at  an  early 
age;  he  found,  however,  that  the  voice  was  not  thus  materially 
improved. 

Trelat  taught  that  the  subsequent  improvement  of  the  voice 
•depended  much  on  the  antero-posterior  diameter  of  the  pharyngo- 
buccal  cavity;  if  this  diameter  be  short,  the  improvement  will  be 
much  less  than  if  the  diameter  be  a  long  one.  These  conditions, 
whether  favorable  or  unfavorable,  are  unchangeable,  and  must 
be  accepted  by  the  operator. 

Passavant,  who  made  this  subject  a  matter  of  research, 
announced,  in  1863,  that  defective  phonation  was  due  to  the 
palatal  tension,  and  the  inability  to  close  the  choanse;  and  as 
corrective  means,  Passavant  advised  to  effect  adhesion  between 
the  palatal  veil  and  the  wall  above;  he  recommended  to  form 
adhesion  between  the  median  .portion  of  the  soft  palate  and  the 
wall  of  the  pharynx,  so  that  only  small  orifices  may  remain. 

Bearing  on  this  subject  Pitha  made  the  observation  that  the 
voice  was  materially  improved  in  a  patient  in  whom  tijere  was 
accidental  closure  of  the  choanne.  Pitha  furtiier  concludes  that 
the  uvula  performs  some  part  in  the  production  of  voice,  and 
hence,  in  his  operations  for  closure  of  cleft  palate,  he  preserved 
the  uvula;  or  if  this  part  did  not  exist,  he  endeavored  to  form  one. 

Mason,  an  English  surgeon,  to  improve  the  voice  after  closure 
of  the  cleft  palate,  cat  away  the  soft  veil  from  the  pterygoid  proc- 
esses, on  each  side,  close  to  the  hamular  process;  the  intention  of 
such  section  was  to  allow  the  closure  of  the  choanse  by  the  pen- 
dulous palate. 

To  improve  the  condition  after  staphylorrhaphy,  Langenbeck, 
in  1885,  advised  to  apply  electricity  to  the  parts,  and  to  practice 
massage  of  the  throat,  and  in  the  latter  work  the  fingers  must 
be  introduced  into  the  throat,  and  the  structures  rubbed  and 
kneaded. 


67(3  PALATAL    CLEFT    OR    DIVISION. 

After  the  staphylorrhaphic  procedure  has  beeu  done,  should 
the  work  not  have  beeu  wholly  successful,  and  one  or  more  gaps 
remain,  the  operator  should  not  hasten  to  repair  these  defects; 
for  undue  haste,  through  the  reopening  of  the  points  of  adhesion, 
may  lose  what  has  been  gained.  But  after  three  months  have 
elapsed,  such  remaining  gap  may  be  trimmed  and  closed  by 
suture.  If  the  opening  be  small,  closure  may  be  attempted  by 
cauterizing  with  the  hot  iron,  nitrate  of  silver,  or  by  cantharidal 
vesication. 

In  the  case  of  cleft  in  the  soft  palate  which  has  been  acquired 
by  wound  or  disease,  closure  may  be  attempted  by  some  of  the 
methods  described  for  closure  of  congenital  cleft.  If  the  breach 
be  a  wound,  of  which  the  edges  are  raw,  closure  may  be  done  by 
simple  suture;  but  if  the  wound  has  cicatrized,  leaving  an  open- 
ing, pare  tiie  borders  of  the  latter  and  unite  by  suture.  But  when 
the  breach  has  originated  from  disease,  an  attempt  at  closure 
should  not  be  done  until  the  tissues  around  the  opening  have 
become  sound  or  freed  from  any  scrofulous  or  syphilitic  taint, 
which  has  been  the  cause  of  the  palatal  perforation.  If  the  cause 
be  syphilitic,  which  is  the  usual  one,  the  patient  must  first  be 
submitted  to  a  course  of  appropriate  treatment  for  a  number  of 
weeks,  until  the  disease  has  yielded;  then  such  o])eration  can  be 
done  with  a  prospectively  successful  event.  If  there  has  been  but 
little  loss  of  structure,  the  work  can  be  done  by  trimming  and 
sutural  closure;  but  if  tlie  breach.be  a  greater  one,  then  lateral 
incisions  must  be  made,  on  one  or  both  sides,  so  as  to  admit  of  free 
movement  towards  the  median  line. 

The  lateral  incisions  which  are  made  to  aid  in  the  closure  of 
congenital  or  acquired  palatal  cleft,  sliould,  in  most  cases,  reach 
quite  through  the  soft  palate,  and  must  be  from  a  half  inch  to  an 
inch  in  length,  and  should  be  made  near  the  lateral,  attached 
part  of  the  pendulous  veil.  In  some  cases  the  writer  has  made 
these  liberating  cuts  after  .sutural  closure  of  the  breach;  for  if 
thus  done,  they  may  be  incised  where  there  is  the  greatest  tension. 

The  lateral  subsidiary  incisions  in  the  soft  palate  soon  close; 
and  so  rapid  is  this  healing  that  some  operators  have  maintained 
them  patent  for  a  time  by  means  of  plugs  of  lint  inserted  in  lliem 
for  three  or  four  days.  There  is  no  danger  that  these  openings 
will  not  heal;  for  plastic  nature,  so  tardy  in  the  median  line  of 
the  palatal  vault,  redoubles  her  effort  to  repair  breaches  along 
the  sides  of  the  roof  of  the  mouth;  slie  seems  indulgent  of  a 
central  breach,  but  cannot  tolerate  a  lateral  one,  and  the  impor- 


URANOPLASTY.  677 

tant  principle  here  figuratively  expressed  is  the  underlying 
groundwork  on  whicli  rests  the  chief  operative  procedures 
resorted  to  for  the  closure  of  clefts  through  the  long  palatal 
vault:  procedures  to  which  the  reader's  attention  is  next  directed. 

Uranoplasty. — Uranoplasty  is  derived  from  Ouranos,  signifying 
the  sky  or  firmamental  vault,  and  plazein,  to  mold;  and  the  pro- 
cedure dates  from  1824,  when  Krimer,  a  German,  made  the  first 
effort  to  close  a  breach  in  the  osseous  vault.  The  operation  was 
done  on  a  girl  eighteen  years  of  age,  in  whom  Krimer  dissected 
up  two  lateral  flaps,  turned  them  over,  and  shifted  them  over  the 
gap.  The  work  was  only  partially  successful.  Near  the  same 
time,  Diefifenbach  performed  a  similar  operation  with  only  partial 
success.  Diefifenbach  proposed  to  divide  or  split  off  a  portion  of 
the  bony  roof,  and  push  this  into  the  opening.  This  operation, 
as  well  as  another  one  proposed  by  Dieffenbach,  in  which  the 
palatal  bones  should  be  united  by  silver  wure,  seems  never  to 
have  been  done  by  him.  In  1850  Biihiing  wrote  that  he  had 
performed  such  an  operation  for  the  closure  of  a  cleft  which  was 
two-thirds  of  an  inch  wide;  following  Dieffenbach,  whom  he  cites, 
Biihring  split  off  the  margins,  and  forced  these  towards  each 
other  by  means  of  lint,  which  was  stuffed  in  the  lateral  openings. 
As  Biihring  had  neglected  to  pare  the  edges,  there  was  no  union 
until,  at  a  later  period,  he  trimmed  the  borders,  reopened  the 
lateral  openings,  introduced  waxed  silken  sutures,  and  thus  suc- 
ceeded in  getting  closure.  In  the  same  year,  Wutzer  published 
an  account  of  similar  operative  work;  he  announced  that,  in 
1834,  he  had  closed  the  bony  palate  in  a  young  man  as  follows: 
cuts  which  exposed  the  bone  were  first  made  antero-posteriorly, 
two  lines  from  the  border  of  the  cleft,  and  then  a  knife  was  thrust 
through  the  soft  palate  at  the  junction  of  the  latter  with  the 
osseous  palate.  Through  such  orifice  made  on  each  side,  a  small 
saw,  made  from  the  mainspring  of  a  watch,  was  passed  and  the 
bone  sawn  through  from  behind  forwards.  Through  the  lateral 
clefts  thus  made  with  the  saw,  strong  threads  were  passed  and  tied 
so  as  to  approximate  the  long  bony  bridges.  -In  this  way  partial 
union  of  the  bridges  was  secured;  the  gaps  which  remained  were 
made  to  close  by  means  of  tincture  of  cantharides.  In  this  man- 
ner complete  closure  was  obtained,  yet  phonation  was  not  much 
improved. 

Roux,  who  had  done  so  much  in  the  field  of  staphylorraphy, 
at  an  early  period,  announced  five  uranoplastic  operations,  of 
which  three  proved  successful.     Uranoplasty,  first  proposed  and 


678  PALATAL    CLEFT    OR    DIVISION. 

done  on  German  soil,  was  cultivated  and  attained  great  perfection 
in  the  hands  of  Bernard  von  Langenbeck,  who  published,  in  1860, 
an  exhaustive  account  of  his  method.  He  first  reviews  the 
method  of  Dieffenbach  of  splitting  off  parts  and  sliding  these 
inwards;  also,  his  own  efforts  to  close  the  breach  by  uplifting  and 
displacing  inwards  the  palatal  mucous  membrane;  but  the 
unsatisfactory  results  gotten  by  these  ways  of  operating,  led 
Langenbeck  to  try  a  third  method,  in  which  he  used,  as  repa- 
rative material,  the  muco-periosteal  covering  of  the  hard  palate. 
He  was  emboldened  to  try  this  plan  from  having  observed  that 
the  detachment  of  the  periosteum  does  not  endanger  the  life  of 
the  uncovered  bone;  also,  that  tissue,  which  is  invested  with 
periosteum  when  placed  on  naked  bone,  will  adhere  to  it;  and 
finally  that  when  tissue  is  shifted  which  carries  periosteum,  the 
latter  will  produce  l)one  in  its  new  situation;  and  thus  the  new 
bone  will  fortify  and  strengthen  the  transplanted  structure.  In 
his  first  essays,  from  the  want  of  proper  instruments,  Langenbeck 
was  unsuccessful ;  later  he  was  more  fortunate,  when  he  was 
armed  with  the  following  instruments:  (1)  Blunt  hooks  to  pull 
back  the  angles  of  the  mouth.  (2)  Mouth  mirror  and  tongue- 
depressor.  (3)  Long-toothed  forceps.  (4)  Assorted  knives,  one 
lance-shaped,  one  with  a  convex  edge,  and  a  third  one  of  sickle- 
shape.  (5)  A  raspatory.  (6)  Elevators.  (7)  Xeedle-holders. 
(8)  Thread  of  different  colors.  (9)  Thread  holders  to  hold  and 
separate  the  threads  which  have  been  passed.  (10)  Sponges, 
syringes  and  forcej)s. 

This  armament  of  instrumental  equipment  is  greater  than 
that  used  by  many  operators;  the  mouth  mirror  and  tongue- 
depressor  were  not  used  by  Dieffenbach,  wdio  says:  "One  must  seize 
the  proper  moment,  as  he  who  would  shoot  a  swallow  on  the 
wing.  And  hence,  one  must  not  use  corks  which  are  forced 
between  the  teeth  to  hold  the  mouth  open;  nor  should  the  tongue 
be  depressed  with  spatula  or  handle  of  a  spoon,  in  order  to  see 
better  antl  have  more  room  to  work  in." 

Langenbeck  begins  by  seizing  the  uvula,  or  side  of  the  soft 
palate,  and  then  he  trims  off  the  border  from  behind  forwards. 
Trim  from  without  inwards,  since  thus  more  of  tiie  mucous  mem- 
brane will  be  removed.  Next,  the  levator  palati  and  the  palato- 
pharyngeus  muscles  are  to  be  severed;  the  latter  is  incised  by 
a  cut,  which  penetrating  near  the  hamular  process  cuts  from 
without  inwards  and  forwards.  This  incision  avoids  t?ie  pos- 
terior palatine  artery.     The  hard  structures  which   invest  the 


URANOPLASTY.  679 

bony  roof  are  next  to  be  divided  on  eacli  side  by  an  incision 
which  passes  along  the  alveolar  process  close  to  the  teeth  and 
reaches  to  the  bone.  These  lateral  cuts  begin  at  tlie  incisions 
that  were  made  to  divide  the  muscles;  and  they  terminate  at  the 
interspace  between  the  inner  and  outer  incisor  teeth.  Or  if  tlie 
closure  can  be  accomplished  by  one  lateral  flap,  let  this  end  in 
front  at  the  space  between  the  outer  incisor  and  the  bicuspid 
tooth.  The  bridges  are  a  third  of  an  inch  wide  in  front;  and 
the  palatal  artery  enters  them  behind.  The  bleeding  that  fol- 
lows can  be  arrested  by  pressure  or  cold  water.  Next  detach  this 
bridge  from  the  bone,  commencing  in  front;  and  in  the  separa- 
tion be  sure  that  the  periosteum  is  uplifted.  The  detachment  of 
the  structures  is  easily  done  behind;  in  front  it  is  tedious,  and 
must  be  done  cautiously. 

When  the  detachment  has  been  completed  to  near  the  pos- 
terior edge  of  the  osseous  roof,  the  posterior  or  upper  mucous 
covering  of  the  velum  is  to  be  divided,  and  the  separation  of  the 
parts  is  then  to  be  continued  until  the  swinging  bridge  is  quite 
detached  from  the  horizontal  palatal  plate;  and  when  this  is 
done,  the  bridge  swings  freely  and  the  two  are  actually  in  contact. 
The  sutures  are  next  inserted,  of  which  the  number  may  vary 
from  ten  to  twenty-two;  and  these  must  be  introduced  from 
before  backwards.  Langenbeck  begins  to  remove  the  sutures  on 
the  fourth  day,  and  finishes  on  the  tenth  day. 

After  the  operation  the  patient  is  to  be  fed  on  liquid  food;  and 
to  allay  tliirst  ice  may  be  given. 

Gangrene  occurred  in  no  case.  There  was  much  swelling  of 
the  shifted  structure,  so  that  the  lateral  vacant  spaces  were  nearly 
covered  on  the  day  following  the  operation.  This  swelling  was 
due  to  the  tumefaction  of  the  uplifted  periosteum.  And  in  no 
case  was  there  necrosis  of  the  bone.  The  periosteum  of  the 
shifted  structure,  which  was  placed  on  the  inner  edge  of  the  gap, 
seemed  to  quickly  adhere  to  the  subjacent  bone;  and  this 
adherence  tended  to  lessen  the  cleft,  in  case  the  bridges  failed  to 
unite  in  the  median  line.  New  bone  was  produced  from  the 
periosteal  surface  of  the  flap  that  covered  the  cleft;  such  new 
osseous  growth  was  verified  in  two  cases,  which  had  been  operated 
on  by  Langenbeck. 

Langenbeck  urgently  insists  that  uranoplasty  should  be  done 
before  staphjdorraphy;  also  that  staphylorraphy  should  not  be 
done  in  infants,  since,  througli  its  interference  with  swallowing, 
nutrition  is  interfered  with.     Two    children,  between  one  and  a 


680  PA  LATA  r,    (LEFT    OK    DIVISION. 

lialf  and  two  and  a  lialf  years  of  age,  operated  on  for  closure  of 
the  soft  palate,  died  from  not  taking  food ;  uranoplasty^  might  be 
done  at  an  early  age,  since  it  does  not  seriously  interfere  with 
swallowing. 

Urano{)lasty  gave  much  improvement  in  speech;  and  this 
was  much  greater  if  the  operation  was  done  before  twelve  years 

of  age. 

Soon  afterwards,  Langenbeck  reported  forty-two  operations  of 
uranoplasty;  in  some  of  the  patients  the  cleft  was  wide,  being 
an  inch  or  more  in  breadth,  and  the  sides  stood  nearly  vertical. 

In  some  of  tlie  patients,  he  let  one  lateral  incision  end  at  the 
inner  incisor  tooth,  and  the  other  at  the  canine  tooth.  Having 
found  that  the  swinging  bridges  often  sank  too  low  when  the 
sides  of  the  cleft  were  vertical,  to  correct  this,  Langenbeck 
resorted  to  the  device  of  intermediate  attachment;  this  consisted 
in  leaving  the  flap  adherent  to  the  bone  adjacent  to  the  first 
molar  tooth.  Such  a  peduncle  of  adhesion  on  each  side,  pre- 
vented the  excessive  swaying  downwards  of  the  swinging  bridges. 
Both  silk  and  silver  sutures  were  used;  yet  preference  was 
given  to  silk. 

In  some  cases,  in  which  one  or  both  sides  of  the  palatal  bones 
stand  vertical,  Langenbeck  varied  the  operation  somewhat  from 
the  plan  above  given;  in  place  of  lateral  peduncular  attachment, 
he  made  an  attaclimcnt  to  the  vomer,  which,  for  this  purpose,  is 
to  be  denuded,  so  that  the  uplifted  flap  can  be  sutured  to  it. 
This  may  be  done  on  one  or  both  sides,  according  as  one  or  both 
palatal  margins  lie  in  vertical  position. 

As  has  been  mentioned,  Langenbeck  let  the  uranoplastic 
operation  precede  that  of  staphylorraphy  in  cliildren;  but  in 
adults  he  advised  that  staphylorraphy  should  precede  urano})lasty. 
Langenbeck  claimed  that  operations  iu  which  palatal  closure 
was  done  materially  improved  the  voice;  and  that  the  improve- 
ment continued  until  the  lingual  defects  nearly  disappeared. 

Soon  after  this  publication,  the  English  surgeons  claimed 
that  a  similar  operation  had  been  done  by  tliem;  Hulke asserting 
that  both  Fergusson  and  Pollock  uplifted  the  i)eriosteum  along 
with  tlie  mucous  membrane,  in  tlie  flap  that  was  used  for  closure 
of  the  palatal  breach.  But  while  tlie.se  discussions  in  regard  to 
priority  were  in  action,  Fergusson  resuscitated  the  abandoned 
method  of  Dieffenbach,  in  which,  on  one  or  both  sides  of  the 
cleft,  portions  of  the  palatal  bones  are  split  off,  and  moved 
median- wards  into  the  breach;  and  in  1876  he  reported  fifty-six 


URANOPLASTY.  681 

operations,  in  which  there  were  but  two  failures;  and  the 
announcement  of  this  successful  work  gave  favor  and  fashion  to 
the  osteo-plastic  procedure.  A  plea  in  favor  of  this  procedure 
is  that  it  dispenses  with  the  tedious  dissection  of  the  muco- 
periosteal  tissue.  And  if  the  cleft  reached  through  both  the  soft 
and  the  hard  palate,  the  closure  of  both  was  comprised  by  Fer- 
gusson  in  one  operation. 

To  perform  this  operation,  the  work  begins  with  paring  the 
edges  of  the  cleft  along  its  total  length;  then  an  incision  should 
be  made  on  each  side,  parallel  with  the  alveolar  process,  but 
somewhat  internal  to  the  latter,  quite  through  the  muco- 
periosteal  structure.  These  lateral  incisions  begin  in  the  soft 
palate,  and  extend  forwards  to  within  a  few  lines  of  the  alveolar 
arch.  Through  the  bone  thus  exposed,  the  blade  of  a  chisel  may 
be  forced,  either  with  the  hand  or  with  a  mallet.  To  make  the 
entrance  of  the  chisel  more  easy,  and  to  prevent  fissured  deflec- 
tion of  the  osseous  wound,  Fergusson  was  accustomed  to  first 
pierce  the  bone  with  a  number  of  openings  by  means  of  an  awl- 
like instrument.  It  may  be  recalled  that  Dieffeiibacli  used  a 
three-angled  borer,  with  which  he  pierced  the  bone  in  the  oper- 
ation of  closing  palatal  cleft.  The  chisel,  with  which  Fergusson 
split  off  the  bone,  was  used  as  a  lever  to  pry  or  force  the  frag- 
ment inwards.  The  lateral  portions  being  thus  prepared,  sutures 
are  introduced,  and  the  parts  united.  In  the  lateral  openings, 
lint  was  introduced.  The  sutures,  in  most  cases,  merely  passed 
through  the  soft  structures;  should  this  not  be  feasible,  holes 
may  be  drilled  through  the  detached  parts,  and  the  sutures  passed 
through  their  margins.  Or,  as  Fergusson  sometimes  did,  the 
sutures  may  pass  through  the  lateral  openings.,  and  thus  closure 
be  done. 

The  writer,  who  has  performed  this  operation  several  times,  has 
sometimes  found  difficulty  in  the  union  of  the  detached  portions; 
and  this  can  occur  where  the  breach  is  very  wide;  also  in  cases 
in  which  one  side  of  the  horizontal  palatal  process  is  attached  to 
the  vomer.  In  case  of  great  breadth  of  breach,  it  requires  sutures 
of  strong  tension  to  effect  median  coaptation;  and  in  such  a 
case,  operated  on  by  the  author,  the  excessive  pressure  on  the 
detached  parts  by  the  wire  in  which  they  were  included,  caused 
strangulation  and  death  of  a  portion  of  the  united  parts;  the 
staphylorrajDhy  was  successful ;  but  the  attempt  to  close  the 
osseous  breach  was  a  partial  failure.  Cases  in  which  such  a 
result  menaces  the  operator,  are  those  in  which,  besides  great 
44 


082  PALATAL    CLEFT    OR    DIVISION. 

width  of  cleft,  the  structures  which  bound  the  cleft  laterally  are 
atrophied,  the  bones  reduced  to  thin  plates,  and  their  covering  to 
film-like  tissue  which  is  poorly  su[)plied  with  blood.  The  writer 
has  seen  such  tissue  which  was  almost  like  tendon  in  its  bloodless 
character.  In  patients  having  a  cleft  of  this  kind,  it  is  wise  to 
leave  the  osseous  breach  untouched,  and  to  limit  the  work  to 
closure  of  the  soft  palate;  the  opening  which  then  remains  may 
be  closed  b}^  an  obturator,  which  can  be  devised  and  constructed 
by  the  mechanical  dentist. 

In  cases  in  which  there  exist  conditions  similar  to  those 
mentioned,  or  in  which  there  has  been  failure  to  obtain  union, 
rather  than  abandon  the  patient  to  the  unending  annoyance  of 
wearing  an  obturator,  there  are  other  operative  methods  by 
which  closure  may  be  attempted.  For  this  purpose,  occluding 
material  has  been  obtained  in  the  nasal  passages,  from  the 
pharynx,  from  the  adjacent  alveolar  wall,  and  from  the  contigu- 
ous cheek;  and,  lately,  a  new  mode  of  closure,  from  the  remaining 
palatal  vault  itself  has  been  proposed  by  an  English  surgeon. 

Lannelongue,  in  187G,  closed  a  cleft  with  material  which  was 
obtained  from  the  nasal  septum;  he  since  reports  two  closures 
thus  effected. 

Schonborn,  in  187G,  reported  the  closure  of  a  cleft  in  the  palate 
by  means  of  material  obtained  from  the  wall  of  the  pharj'iix. 
The  aim  of  Schonborn  was  to  close  the  breach  in  such  a  way  that 
the  posterior  nares  would  be  closed,  and  thus  phonation  improved. 
To  do  tliis,  a  flap  which  was  nearly  an  inch  wide,  and  two  inches 
long,  was  dissected  up  from  the  pharyngeal  wall,  and  this  flap, 
adhering  below,  was  inclined  forwards  and  sutured  in  the  gap. 
By  such  a  procedure,  Schonborn  thinks  a  defective  velum  might 
be  repaired. 

In  1868,  Thiersch  reported  that,  two  years  previously,  he  had 
closed  a  breach  in  a  hard  palate,  in  which  a  uranoplastic  opera- 
tion had  failed  in  the  following  unique  manner:  two  teeth 
were  removed  from  the  side  of  the  upper  jaw,  and  then  a  section 
of  the  alveolar  process  was  removed  with  a  chisel.  Through  the 
breach  thus  made,  there  was  carried  a  flap  which  had  been 
formed  from  the  entire  thickness  of  the  cheek.  This  flap  was 
over  two  inches  long,  and  was  fastened  in  the  cleft  by  eight 
sutures.  The  gingival  integument  was  preserved  so  that  the 
exposed  portions  of  the  alveolar  process  were  fully  covered  there- 
with. The  scar  which  remained  in  the  cheek  was  not  conspicu- 
ous.    A  portion  of  the  flap   died,  yet  enough    lived  to  greatly 


URANOPLASTY. 


683 


improve  the  patient's  condition.  An  inconvenience,  however, 
was  afterward  experienced  from  the  beard  growing  from  the  flap 
which  had  been  transplanted  into  tlie  mouth. 

The  alveolar  processes  have  furnished  material  for  closure  of 
the  anterior  portion  of  the  osseous  cleft ;  and  as  these  cases  are 
often  associated  with  hare-lip,  in  the  operation  of  repairing  the 
lip,  something  may  be  done  in  closing  the  adjacent  palatal 
breach.  When  the  bony  cleft  is  a  small  opening,  the  closure  of 
the  labial  cleft  in  the  infant  will  aid  in  the  spontaneous  closure 
of  the  front  portion  of  the  palatal  cleft;  but  if  the  latter  be  a  larger 
breach,  then  something  more  should  be  done,  in  case  the  patient 
be  a  child.  For  this  purpose,  on  one  side  in  the  bicuspid  region, 
divide  the  alveolar  arch  vertically  with  a  small  saw;  and  having 
drilled  holes  through  the  process  on  each  side  of  the  cleft,  pass  a 
sfilver  wire  through,  and  close  the  median  cleft,  leaving  a  lateral 
one  in  the  arch,  which  will  afterwards  fill  up.  In  this  work  of 
median  displacement,  care  must  be  used  to  spare  the  dental 
roots;  neglect  of  this  rule,  cost  the  patient  a  tooth  in  a  case 
operated  on  b}''  the  author. 

Another  procedure  has  been  announced,  in  1890,  for  the  closure 
of  the  osseous  cleft;  its  author,  Davies-Colley,  proposes  its  use 
especially  in  cases  in  which  there  has  been  a  failure  to  get  union 


Figure  88.    Showing  Davies-Colley's  uranoplastic  procedure. 

by  some  other  method.  The  understanding  of  this  procedure,  is 
facilitated  by  the  accompanying  diagram,  Figure  88.  To  do 
this,  two  flaps  are  to  be  constructed  from  the  hard  structures  of 
the  bony  palate.     The  first,  formed  on  the  broader  side,  is  made 


684 


PALATAL    CLEFT    OR    DIVISION. 


by  an  incision,  which,  commencing  at  a,  near  the  last  molar 
tooth,  runs  forwards  along  the  alveolar  arch  to  h,  near  the 
incisior  teeth ;  thence  it  curves  inwards  and  runs  backwards  near 
the  margin  of  the  cleft,  until  it  reaches,  at  c,  the  soft  palate.  The 
flap  thus  traced  out  is  now  to  be  carefully  dissected  from  the 
bone.  Next  an  incision  is  made  on  the  other  side,  which  is  to 
begin  near  the  anterior  end  of  the  cleft  at  d,  and  thence  passing 
outwards  to  the  alveolar  arch,  it  is  to  be  carried  backwards 
along  this  arch  to  e,  in  the  soft  palate,  where  the  cut  ends 
near  the  cleft.  The  structure,  thus  circumscribed,  is  to  be 
dissected  from  the  bone,  so  that  there  will  be  formed  a  semi- 
elliptical  flap,  which  has  attachment  along  the  inner  margin  of 
the  cleft.  This  flap  is  now  folded  inwards  so  as  to  lie  on,  and 
close  the  greater  part  of  the  palatal  cleft.  To  retain  this  flap  in 
place,  two  or  three  sutures  are  used.  Next,  tlie  pedunculated 
flap  from  the  other  side  is  turned  across  the  median  line,  so  that 
its  raw  surface  will  rest  on  the  raw  surface  of  the  previous  flap; 
and  this  is  retained  in  ])lace  by  a  few  sutures  which  pass  through 
its  anterior  end.  Should  this  cros.sing  flai>  not  readily  reach  to 
the  point  where  it  is  to  be  fastened,  then  the  flap  must  be  dis- 
sected up  somewhat  more  at  its  base.  The  procedure  of  Davies- 
CoUey  when  completed  is  shown  in  Figure  89. 


Figure  89.    Showing  the  appearance  after  closure  of  tlie  parts  according  to 
the  plan  of  Davies-Colley. 

Davies-Colley,  who  recommends  this  operation  in  infants  in 
whom  the  breach  is  wide,  or  in  whom  an  operation  has  failed, 
gives  the  following  as  its  advantages  and  disadvantages:  its 
advantages  are  that  there  is  less  haemorrhcige ;  less  bruising  of 


URANOPLASTY.  685 

the  parts ;  less  sacrifice  of  tissue,  less  tension  of  flaps ;  and  it  can 
be  performed  at  an  early  age,  viz ,  between  one  and  two  years  of 
infancy.  Its  disadvantages  are  that  the  bony  palate  alone  is 
closed,  and  that  an  opening  is  apt  to  be  left  in  the  front  part  of 
the  cleft. 

In  concludingthe  chapter  on  staphylorrhaphy  and  uranoplasty, 
it  must  be  added  that,  though  surgery  has  accomplished  here 
some  of  its  most  commendable  achievements,  yet  tlie  best  work 
done  seldom  greatly  improves  the  patient's  defective  speech;  to 
drop  his  ill  sounds,  and  to  acquire  the  normal  shaping  and 
expression  of  the  elements  of  articulate  language,  depend  on  the 
individual  effort  of  the  patient;  he  is  in  the  position  of  one  who 
learns  a  new  language;  he  need  not  hope  to  reach  faultless 
excellence,  yet  perseverance  will  bring  him  towards  such  a  goal; 
possibly  so  near,  that  he  will  not  differ  much  from  the  many  who 
have  no  palatal  defect.  Besides  diligent  practice  in  articulation^ 
in  which  there  must  be  repeated  a  series  of  words  containing  the 
.defectively  pronounced  sounds,  there  should  be  practiced  passjve 
motion  of  the  parts,  in  the  form  of  friction,  massage  and  knead- 
ing. But  to  accomplish  any  great  benefit,  there  must  be  an 
unabated,  untiring  effort;  fortunately,  the  desire  to  escape  from 
the  chagrin  which  the  sound  of  his  voice  continually  renews  in 
the  rational  child  or  adult,  is  generally  present  as  a  prompting- 
spur  to  such  diligence.  The  implantation  in  the  human  lieart 
of  the  desire  to  merit  the  approval  of  others  lies  at  the  foundation 
of  things  great  and  small;  it  builds  a  bulwark  in  defense  of  pub- 
lic morals;  and  equally  awakens  in  the  individual  a  dislike  of  his 
abnormal  feature  or  word,  and  inspires  him  with  courage  to- 
break  the  fetters  of  such  embarrassment. 


CHAPTER   XX. 


TOXSIL. 


Surgicol  Anatomy. — The  tonsil's  function,  though  the  part  is 
so  accessible  to  research  and  inspection,  remains  to  be  determined; 
if  a  collection  of  lymphatic  glands,  as  some  contend,  it  has  failed 
to  be  the  metastatic  point  for  development  of  the  elements  of 
malignant  disease  which  may  be  located  in  the  tongue,  pliarynx 
or  choanae.  It  is  composed  of  closed  spheroidal  spaces  or  vesicles, 
which  are  adjacent  to  depressions  which  mark  the  surface  of  the 
tonsil;  and  from  the  resemblance  of  this  surface  to  tliat  of  an 
almond,  the  tonsil  has  derived  the  name  by  which  it  is  popularly 
known  in  some  languages. 

The  tonsil  lies  between  the  arches  of  the  palato-glossus  and 
palato-pharyngeus  muscles;  and  as  these  arches  do  not  stand 
vertical,  so  the  contained  tonsil  has  an  oblique  position  from 
before  backwards,  and  from  without  inwards;  and  this  obliquity 
permits  the  view  of  the  part  when  the  jaws  are  fully  separated. 
Its  vokirae  is  variable;  nominally  it  is  a  half  inch  long,  a  third 
of  an  inch  thick,  and  the  same  in  l)readth,  and  when  it  is  of  this 
normal  size,  the  tonsil  scarcely  rises  beyond  the  sides  of  tlie  arches 
which  inclose  it. 

The  tonsillar  surface,  instead  of  being  dotted  with  depressions, 
may  be  entirely  smooth,  or  the  surface  may  be  rough  and  irreg- 
ular in  consequence  of  ulceration  or  suppuration.  And  again, 
there  have  been  seen  cases  in  which  the  tonsil  presented  near  the 
middle  part  of  its  surface  a  gap  or  common  space,  into  which  all 
the  mucous  follicles  emptied.  The  deeper  or  external  portion  of 
the  tonsil  rests  on  the  superior  constrictor  of  the  pharynx. 

Between  the  ramus  of  the  lower  jaw  and  the  pharynx  exists 
a  prismoidal,  triangular  space  named  the  maxillo-pharyngeal 
space;  its  base  rests  against  the  vertebral  column,  and  its  narrow 
part  ends  at  the  insertion  of  the  constrictor  muscles.  In  tliis 
space  are  contained  the  internal  carotid  artery,  the  internal  jugu- 
(686) 


SURGICAL    AXATOMY.  687 

lar  vein,  and  the  pneumogastric  and  sympathetic  nerves.  The 
tonsil  rests  on  the  inner  T^'all  of  this  space  and  has  close  relations 
with  the  internal  carotid  artery;  the  vessel  lies  outwards  and 
backwards  from  the  tonsil,  while  the  internal  pterygoid  muscle 
lies  inwards  and  forwards.  The  insertion  of  the  pterygoid  muscle 
into  the  angle  of  the  jaw,  and  the  position  of  this  angle,  are  such 
in  reference  to  the  tonsil  that  the  latter  can  be  pressed  outwards 
against  the  jaw;  this  fact,  pointed  out  by  Richet,  was  utilized  by 
him  in  the  establishment  of  compression  of  the  tonsil  in  the  case 
of  a  haemorrhage  from  the  part. 

An  occasional  abnormal  situation  of  the  internal  carotid 
artery  was  noted  by  Chassaignac;  he  observed  that  sometimes  in 
the  aged  subject,  the  vessel  in  the  maxillo-pharyngeal  space  is 
curved  inwards,  with  convexity  directed  towards  the  tonsil,  so 
that  the  artery,  in  such  a  case,  is  unusually  imperiled  through  a 
wound  of  the  tonsil. 

The  tonsil  receives  its  blood  from  the  inferior  palatine,  which 
is  a  branch  of  the  facial  artery;  also  from  the  ascending  pharyn- 
geal branch  of  the  external  carotid,  and  from  the  posterior 
palatine,  a  branch  of  the  internal  maxillary  artery.  Hyrtl  has 
observed  an  occasional  anomaly  in  which  the  inferior  palatine 
artery  (called  also  the  internal  palatine)  is  so  large  as  to  replace 
the  internal  maxillary  artery;  and,  in  such  case,  the  inferior 
palatine  gives  off  the  branches  which  are  normally  derived  from 
the  internal  maxillary  artery.  Such  enlarged  anomalous  vessel 
might  be  the  source  of  a  dangerous  bleeding.  Normally,  the 
external  carotid  is  so  distant  from  the  tonsil  that  a  wound  of  the 
latter  could  not  reach  it;  j^et  Flihrer  has  shown  that  from  a 
morbid  rigidity  of  the  vessel,  where  it  passes  behind  the  posterior 
belly  of  the  digastric,  the  external  carotid  can  approach  so  near 
the  tonsil  that  the  vessel  would  be  imperiled  in  extirpation  of  the 
tonsil.  Besides  the  structures  which  lie  in  the  maxillo-pharyngeal 
space,  there  is  a  loose  cellulo-adipose  tissue  wliich  communicates 
with  the  cellular  tissue  of  the  neck;  and  through  this  tissue 
inflammation  located  in  the  tonsil  can  travel  downwards;  and  in 
case  of  suppuration,  the  pus  has  appeared  below  the  chin,  and  on 
the  neck  even  as  low  as  the  clavicle;  at  this  remote  point  it  was 
observed  by  Yelpeau. 

In  regard  to  the  site  of  the  tonsil  some  further  points  should 
be  noted.  It  may  be  wholly  sessile,  and  be  closely  adherent  to 
the  parts  in  which  it  rests;  or  it  may  be  so  loosely  attached, 
especially  in  cases   in  which  it  is  enlarged,  that  it  is  so  easily 


688  TONSIL. 

moved  that  it  seems  to  be  peduncated ;  in  fact,  the  free  portion  is 
much  larger  than  that  of  the  base.  It  also  sometimes  extends 
so  far  downwards  in  its  fossa  that  the  lower  part  can  only  be 
seen  b}^  depressing  the  tongue.  The  tonsil  may  scarcely  reach  to 
the  environing  arches;  or  it  may  extend  to  them  so  as  to  be 
tightly  embraced,  or  even  constricted  by  the  arches;  a  constric- 
tion w'hicii  augments  when  the  arches  are  inflamed.  In  such 
anatomical  condition,  the  astringent  application  used  to  allay 
inflammation  seated  here,  would  add  to,  rather  than  abate,  the 
congestion  of  the  tonsil. 

An  important  anatomical  relation,  which  the  writer  has 
frequently  seen,  is  the  adherence  of  the  stylo-glossus  or  stylo- 
pharyngeus  muscle  to  the  tonsil;  in  some  cases  the  arches  may 
be  so  shifted  upon  the  body  of  the  tonsil  that  the  latter  is  partly 
buried  up;  the  arch  being  so  continuous  with  the  tonsil,  that  it  is 
not  easy  to' separate  one  from  the  other.  In  this  way  the  upper 
posterior  portion  may  be  concealed.  Such  adherence  or  muscular 
development  may  conceal  pus  which  is  seated  in  the  upper 
posterior  part  of  the  tonsil,  and  it  may  also  greatly  interfere  with 
the  excision  of  the  part. 

Chassaignac  describes  what  he  names  a  '"demi-capsule"  of  the 
tonsil.  This  structure  lies  on  the  outer  face  of  the  part  and 
separates  it  from  the  constrictor  muscle.  This  capsular  structure 
is  much  denser  and  stronger  than  the  remaining  tissue  of  the 
tonsil;  for  if  one  pushes  a  probe  through  the  tonsil,  it  is  arrested 
by  the  capsule,  which  is  difficult  to  perforate.  He  claims  that 
this  capsular  septum  afifords  protection  in  the  work  of  enucleating 
the  tonsil. 

Chassaignac  also  describes  a  movement  of  the  tonsil,  which  he 
calls  "spiroid;"  this  is  seen  when  the  base  of  the  tongue  is 
depressed;  also  when  there  is  the  movement  of  retching  or  vom- 
iting in  the  throat;  at  such  times,  the  tonsil  will  be  found  to  make 
a  rotatory  movement,  in  the  direction  of  the  vertical  plane  in 
which  it  lies.  The  writer  has  seen  that  this  movement  sometimes 
interferes  with  seizing  the  tonsil,  in  the  work  of  excision. 

Tonsillitis. — Tonsillar  inflammation  has  been  named,  according 
to  the  casual  agency  which  produced  it,  catarrhal,  rheumatismal, 
exanthematous,  etc.  Many  of  these  cases  lie  outside  of  the 
province  of  surgery. 

The  clinical  conditions  and  manifestations  present  in  inflam- 
mation of  the  tonsil  are  the  following:  There  is  the  feeling  as  if 
there  were  some  body  in  the  throat,  which  the  patient  tries  to 


TONSILLITIS.  689 

dislodge  and  swallow,  or  expel  from  the  throat;  and  these  move- 
ments are  often  involuntary,  and  are  the  sources  of  pain  and 
annoyance;  such  pain,  at  first  slight,  soon  increases,  and  finally 
becomes  very  severe;  and  then  swallowing  becomes  nearly  impos- 
sible; in  fact,  the  passage  of  a  small  quantity  of  fluid  excites  a 
j)ainful  cough,  and  some  of  the  passing  material  enters  the 
posterior  nares.  In  the  worst  cases,  the  breathing  is  so  difficult 
that  the  patient,  if  an  adult,  fears  strangulation.  The  pains 
shoot  towards  the  ears;  and  from  swelling,  the  Eustachian  tube 
may  be  partly  or  wholly  closed,  and  some  deafness  thus  arise. 
Or  the  swelling,  valve-like,  may  momentarily  occlude  the  tube, 
and  then  the  part  may  reopen;  and  thus  a  painful  crackling 
arises;  especially,  when  the  lower  jaw  is  moved.  The  face  is 
flushed;  the  tongue  is  often  dry  from  breathing  through  the 
mouth,  and  the  pulse  accelerated,  and  the  temperature  elevated. 
Should  the  swelling  descend  into  the  larynx,  the  dyspnoea  may 
become  so  great,  that,  to  escape  the  impending  suffocation,  tra- 
cheotomy has  been  done;  usuall}',  however,  relief  may  otherwise 
be  obtained. 

The  normal  secretion  of  the  tonsil  is  increased  in  amount, 
and  is  altered  in  character;  it  is  extremely  tenacious  and  adher- 
ent to  the  pharynx,  so  that  there  is  excited  a  teasing  cough, 
accompanied  by  repeated  efforts  to  clear  the  throat. 

The  site,  extent  and  nature  of  the  disease  are  to  be  learned 
by  an  inspection  of  the  pharynx.  In  the  adult  this  can  usually 
be  done  through  simply  directing  him  to  open  his  mouth,  breathe 
outwards,  and  articulate  the  sound  ah;  but  in  some  cases,  it  is 
not  easy  to  open  the  mouth ;  the  lower  jaw  is  fixed  by  contraction 
of  the  masseter  muscles  against  the  upper  jaw,  so  that  it  is  with 
some  effort  that  the  mouth  can  be  opened.  When  this  can  be 
voluntarily  done,  then  by  means  of  the  handle  of  a  spoon  or  a 
tongue  spatula,  the  base  of  the  tongue  can  be  pressed  downwards, 
and  a  full  view  of  the  tonsils  obtained.  This  work,  in  the  adult, 
can  be  done  with  the  surgeon's  finger;  and  often,  as  the  writer 
has  verified,  the  index,  by  pressure  at  different  points,  can  open 
a  view  which  cannot  be  obtained  with  any  tongue  depressor. 
But  woe  betide  the  finger  that  is  thus  trusted  in  the  child's 
throat;  it  may  be  badly  bitten;  and  wdiat  is  worse,  it  may  when 
wounded  be  poisoned  by  the  septic  fluids  of  the  mouth;  hence  the 
use  of  the  tongue  depressor  is  preferable. 

To  inspect  the  child's  pharynx  and  tonsils  is  often  a  diflf^cult 
matter;  the  youngster,  with  the  liberty  of  childhood,  fortified  by 


690  TONSIL. 

indocility,  in  wliich  the  parents  take  i)ride,  declines  to  open  liis 
mouth;  and  will  only  do  so  under  a  discipline  to  which  he  has 
b.een  a  stranger.  In  such  a  contest,  the  surgeon  stands  in  a 
position  not  to  be  envied  ;  but  a,s  it  is  a  contest  in  which  disci- 
pline wages  war  with  the  raw  recruit,  the  former  usually  wins; 
yet  to  insure  liis  victory,  the  surgeon  would  do  well  to  exclude 
the  parents  from  the  scene ;  as,  from  the  writer's  experience,  an 
appeal  to  the  latter  may  render  the  contest  a  much  more 
doubtful  one. 

In  the  exploratory  view  one  learns  the  extent  of  tlie  disease, 
whether  one  or  both  tonsils  are  affected,  and  in  which  one  the 
swelling  is  greater ;  for,  as  a  rule,  one  is  much  more  affected  than 
the  other.  The  swollen  tonsil  is  often  covered  with  a  film  of 
pseudo-diphtheritic  matter. 

The  trismus-like  contraction  of  the  masseter  muscle  is  so 
great  sometimes,  that  the  lower  jaw  cannot  be  depressed,  and  an 
accurate  view  of  the  pharynx  is  prevented.  In  such  condition, 
should  the  disease  be  of  much  gravity,  it  will  be  necessary  to 
open  the  jaws  by  the  aid  of  an  interdental  lever ;  an  instrument 
consisting  of  two  blades  which  are  united  at  one  end,  and  are 
separable  at  the  other  by  means  of  a  screw,  which  being  turned 
lifts  one  blade  from  the  other.  Through  the  space  thus  opened 
both  eye  and  finger  can  explore  the  pharynx. 

Fortunately  for  the  patient,  the  acutely  inflamed  tonsil  runs 
a  rai)id  course,  and  ends  by  resolution  or  suppuration ;  or  the 
inflammation  may  lapse  into  a  chronic  form,  and  then  it  can 
entail  a  permanent  enlargement. 

In  the  disappearance  of  the  tonsillitis  by  resolution,  the  pain, 
swelling  and  dysphagia  gradually  vanish,  and  the  tenacious 
mucous  secretion  disappears;  or  it  is  transformed  into  normal 
mucus.  The  diminution  of  volume  is  sometimes  promoted  by 
the  bleeding  which  sometimes  arises  from  the  bursting  of  blood- 
vessels in  the  surface  of  the  inflamed  part. 

In  case  both  tonsils  are  inflamed,  one  is  commonly  more 
severely  affected  than  the  other;  and  thus  one  may  be  the  site  of 
resolution  and  the  other  of  suppuration. 

In  almost  all  cases  of  acute  tonsillitis,  the  ending  is  in  the 
formation  of  pus;  and  such  event  is  heralded  by  increase  of  the 
swelling  and  pain,  and  augmentation  of  the  tonsillar  and  salivary 
secretions.  The  pain,  though  constant,  appears  in  accessions  of 
greater  intensity,  which  reveal  themselves  in  facial  contortions. 
The  patient  is  tormented  with  a  sense  and  fear  of  suffocation,  due 
to  increasing  narrowness  of  the  fauces. 


TONSILLITIS.  691 

The  pus  in  its  site  may  be  superficial,  deep  or  subtonsillar. 
It  may  be  in  the  front,  posterior,  or  inferior  part  of  the  tonsil;  or 
it  may  be  in  the  summit;  and  when  in  tlie  summit,  or  posterior 
part,  it  may  be  partly  covered  with  the  pharyngeal  arch,  and 
masked  from  view.  It  may  likewise  be  invisible  when  located 
in  the  lower  part  of  the  tonsil ;  and  in  this  situation  the  patient's 
life  may  be  further  imperiled  by  swelling  and  oedema  reaching 
into  the  lar3^nx.  Pus  in  this  inferior  site,  in  opening  may  descend 
into  the  larynx  and  asphyxiate  the  patient. 

Pus  formed  in  the  subtonsillar  location  instead  of  pointing 
towards  the  fauces,  has  been  known  to  form  for  itself  a  way 
through  the  outer  wall,  and  to  appear  beneath  the  skin  at  the 
angle  of  the  jaw;  or  it  may  gravitate  downwards  and  appear  on 
the  side  of  the  neck  even  as  low  as  the  clavicle. 

Weber  has  described  a  species  of  suppurative  inflammation 
which  commences  beneath,  or  within  the  pharyngeal  muscles, 
which  implicates  the  .tonsil.  And  this  affection  sometimes  takes 
on  a  phlegmonous  character,  and  then,  under  the  name  of  phleg- 
monous angina,  it  occupies  a  large  portion  of  the  pharyngeal 
wall.  This  form  of  disease  is  of  a  graver  character  than  any  of 
the  preceding  ones  described  ;  it  may  have  a  rapidly  fatal  termi- 
nation, as  the  writer  has  witnessed  in  a  few  cases. 

In  severe  cases  of  tonsillitis,  whether  ending  or  not  ending  in 
suppuration,  the  disease  induces  swelling  of  the  adjacent  soft 
parts;  and  in  this  tumefaction  the  glands  participate,  which  are 
situated  in  the  parotidean  sulcus  behind  the  ramus  of  the  jaw. 
These  glands  rarely  suppurate.  The  cervical  tumefaction  induces 
a  temporary  wry-neck. 

When  the  event  is  the  formation  of  pus,  the  site  of  this  may 
often  be  detected  with  the  finger  before  it  is  visible  to  the  eye. 
Unless  deep-seated  the  pus  soon  approaches  the  surface,  and,  with- 
out aid,  will  open  itself  a  way  into  the  pharynx.  If  located  deep 
in  the  tonsil,  the  material  may  reach  the  internal  carotid  artery, 
and  by  erosion  open  this  vessel.  Grissole,  Caytan  and  Le  Fort 
report  each  a  case  in  which  this  accident  happened.  Caytan  saw 
a  case  in  which  a  secondary  suppuration  ensued,  and  the  latter 
penetrated  the  artery  and  caused  a  fatal  haemorrhage;  the  open- 
ing was  spontaneous.  The  history  of  the  cases  reported  by 
these  surgeons  shows  that  the  bleeding,  which  has  sometimes  fol- 
lowed the  lancing  of  a  suppurated  tonsil,  may  have  arisen  from 
the  erosion  of  pus  rather  than  from  the  point  of  the  lance.  It  is 
fortunate  that  in  the  field  of  operative  surgery  such  perad ventures 


692  TONSIL. 

exist,  in  which  the  surgeon's  conscience  and  reputation  may 
find  refuge  when  his  thoughtfully  planned  work  ends  in  failure. 
Though  in  such  refuge  the  bitter  flavor  of  disappointment  may 
alloy  the  solace  therein  found,  still  the  result  is  to  stimulate  the 
professional  mind  to  renewed  vigilance  in  operative  effort,  and  to 
more  carefully  studied  endeavor;  and  if  the  surgeon's  work  be 
thus  planned  and  guarded,  the  deciding  balance  will  rarely  incline 
towards  n  on -success. 

Tonsillitis  may  terminate  in  gangrene  of  the  part.  Such 
event  has  been  seen  by  Trousseau,  Hardy,  Frank  and  Borsieri. 
According  to  Borsieri,  tonsillar  gangrene  is  the  expression  of  the 
highest  intensity  of  tonsillitis.  It  probably  depends  on  some 
special  condition  of  the  body;  and  perhaps  is  due  sometimes  to 
infection  of  the  part  with  some  toxic  agent.  That  such  infection 
does  not  occur  oftener  is  a  wonder,  when  one  considers  the  hetero- 
geneous materials  which  are  in  constant  transit  across  the  phar- 
yngeal isthmus,  and  the  numerous  follicular  pockets  into  which 
these  matters  may  pass  and  find  lodgment,  and,  by  retention, 
become  septic,  if  they  were  not  primarily  so.  And  from  such 
morbific  cause  disease  proportioned  to  the  originating  agency 
can  arise;  and  such  tonsillar  affection  may  vary  in  grade  from 
a  transient  irritation  to  a  destructive  gangrene. 

Other  concomitants  of  tonsillitis  are  affection  of  hearing,  and 
palsy  of  the  muscles  concerned  in  deglutition. 

The  inflammation,  as  has  been  stated,  is  seldom  limited  to  the 
tonsil;  it  often  travels  to  the  Eustachian  tube,  and,  entering  this 
canal,  may  so  swell  its  w^alls  as  to  nearly  or  quite  occlude  the 
passage;  and  thence  arises  temporary  deafness,  which  may  be 
partial  or  comi)lete.  Such  impaired  hearing  vanishes  as  the 
tumefaction  subsides.  But  if  the  disease  pass  along  the  tube  to 
the  tympanum,  and  suppuration  occur  there,  the  hearing  of  that 
ear  is  seriously  compromised.  And  in  the  worst  cases,  the  sup- 
purative process,  wandering  far  from  its  tonsillar  site,  has  passed 
to  the  tympanum,  and  thence  it  has  migrated  and  entrenched 
itself  within  the  mastoid  antrum,  requiring,  in  such  cases,  the 
opening  of  the  outer  wall  of  the  mastoid  bone.  Suchniigratory 
action,  fortunately,  is  rarely  seen. 

Palsy  of  the  pharyngeal  muscles  originating  in  tonsillitis,, 
has  been  observed.  Its  appearance  in  the  tonsillitic  patient 
is  much  less  frequent  than  in  the  diphtheritic;  so  much  so 
that  in  the  cases  reported  it  was  claimed  that  there  had  been 
an  error  in  diagnosis.     Palsy  thus  arising  may  be  limited  to  the 


TONSILLITIS.  693 

site  of  the  inflammation,  or  it  may  be  much  more  diffused.  It 
appears  early.  From  the  loss  of  movement  of  the  palatal  veil 
the  tone  of  the  voice  is  altered;  and  the  approach  of  the  paralysis 
may  be  suspected  when  a  nasal  tone  of  voice  is  perceived. 
Besides  phonation,  deglutition  suffers  from  pharyngeal  palsy;  in 
swallowing,  food  may  stray  into  the  air-passages,  and  in  order  to 
swallow,  the  patient  is  sometimes  forced  to  close  the  nostrils;  for 
such  closure,  in  some  degree,  replaces  the  normal  closure  of  the 
choanse  by  the  palatal  veil.  In  this  condition  an  inspection  of 
the  pharynx  will  show  that  the  pendulous  veil  is  hanging  loosely, 
and  if  the  parts  be  touclied,  they  are  insensible  and  are  not 
awakened  to  normal  reflex  movements.  The  possible  ill  result- 
ing from  such  palsy^is  the  passage  into  the  larynx  of  foreign 
materials,  as  particles  of  food,  which  entering  the  lungs  may  irri- 
tate and  inflame  their  tissue;  and  in  a  patient  already  reduced  in 
strength,  from  such  irritant  ichorous  pneumonia  may  originate. 

This  paralytic  condition  of  the  throat  is  sometimes  followed 
by  retinal  affection;  and  vision  is  impaired  from  this  cause  as 
well  as  from  interference  with  the  power  of  accommodation. 

In  a  few  cases  this  anginous  palsy  has  become  general,  and 
ihe  patient  has  been  deprived  of  motion  in  large  sections  of  his 
body.  This  paraly.sis,  both  local  and  general,  is  rarely  permanent 
in  duration. 

A  singular  complication  of  tonsillitis  is  that  in  which  the 
genital  organs  become  consecutively  affected.  In  1857,  Verneuil 
reported  his  observation  of  a  case  in  which  there  occurred  an 
effusion  into  the  tunica  vaginalis  testis,  as  a  metastatic  sequel  of 
inflammation  of  the  fauces.  He  claims  that  there  is  a  morbid 
determination  towards  the  genital  organs  in  tonsillitis.  In  1859, 
James,  an  English  writer,  endeavored  to  show  that  there  is  the 
relation  of  cause  and  effect  between  tonsillitis  and  an  affection  of 
the  ovaries.  In  a  young  woman  who  was  the  subject  of  a  ton- 
sillitis, James  saw  implication  of  the  ovary  corresponding  to  the 
inflamed  tonsil;  and  then,  the  other  tonsil  inflaming,  the  ovary 
on  that  side  also  became  inflamed. 

In  1886,  Joal  and  Verneuil  reported  observations  of  similar 
metastasis,  in  which  orchitis  or  ovaritis  appeared  consecutive  to 
tonsillitis;  the  cases  were  not  seen  in  those  under  pubert}^  nor  in 
the  aged;  and  such  secondary  disease  lasted  from  fifteen  to 
twenty  days. 

Youth  is  much  oftener  the  subject  of  tonsillitis  than  infancy 
or   old  age,   and    the   young,  vigorous   and  robust   are   oftener 


694  TONSIL. 

attacked  than  those  of  feeble  liabit.  Its  causatiou  is  obscure:  in 
fact,  undetermined;  yet  its  fre(iuent  coincidence  with  exposure 
to  cold  air,  or  sudden  change  of  temperature,  makes  it  probable 
that  such  variation  has,  at  least,  a  predisposing  agency.  As  a 
rule  recovery  may  be  expected. 

Treatment.  —  Louis  and  others  claim  that  tonsillitis  is  not 
materially  sliortened  in  its  course  by  treatment;  in  cases  which 
were  vigorously  treated  Louis  reports  that  the  disease  ended  in 
nine  clays ;  but  when  it  was  allowed  to  run  its  course,  it  lasted  but 
one  day  longer.  Few  patients,  however,  are  tolerant  of  passive 
expectation;  and  should  the  physician  imbued  with  tiie  nihilistic 
skepticism  in  his  art,  now  prevalent,  prefer  to  confide  the  matter 
to  nature,  he  will  scarcely  find  concurrei^ce  on  the  part  of  the 
patient.  And  an  extended  observation  has  convinced  the  writer 
that  a  proper  management  of  tonsillitis  both  abridges  the  disease 
and  greatly  ameliorates  the  patient's  condition. 

A  century  ago,  when  venesection  was  the  cliief  weapon 
wielded  against  disease  of  the  sthenic  type,  acute  tonsillitis,  with 
kindred  inflammatory  affections,  rendered  tlie  customary  tribute. 
This  practice,  after  being  consigned  to  seeming  oblivion  for  a 
time,  has  recently  been  recalled  into  use;  Aran,  Mestivier  and 
others  have  reported  excellent  results  from  general  bleeding. 
The  mass  of  recent  authority,  however,  is  unfavorable  to  general 
blood-letting;  the  latter  is  being  superseded  by  the  use  of  leeches, 
externally  applied,  or  by  scarification  of  the  inflamed  surface. 
The  use  of  leeches,  applied  to  the  skin  as  near  as  possible  to  the 
affected  part,  has  been  done;  experience  not  confirming  the  ben- 
efit once  claimed  for  leeching,  this  practice  is  being  abandoned; 
in  fact,  instead  of  relief  following  the  abstraction  of  blood  by 
leeches,  it  is  claimed  tliat  the  patient  is  rendered  worse  by  the 
local  congestion  which  is  thus  induced. 

Mention  should  be  made  of  venesection  from  the  ranine  or 
sublingual  veins;  such  treatment  was  recommended  by  numer- 
ous ancient  authorities,  as  Hippocrates,  Galen  and  many  others. 
The  fear  of  causing  a  hemorrhage  which  would  be  diflieult  to 
check,  inspired  some  of  the  lines  of  caution  which  Celsus  has 
written  when  treating  of  operations  in  the  sublingual  region. 
And,  tliough  bleeding  from  these  ve.'^sels  has  lost  much  of  its 
ancient  credit,  yet  Aran  states  that  in  the  Department  of  the 
Gironde  such  bleeding  is  still  commonly  practiced,  and  praised 
in  the  treatment  of  tonsillitis.  Aran  has  so  often  been  witness  to 
the  good  effects  of  such  depletion,  that  he  advocates  its  use.     And 


TOXSILLITIS.  695 

the  writer  would  add  that  there  scarcely  would  have  been  such 
unanimity  among  the  ancients  in  the  use  of  such  bleeding,  if  it 
did  not  possess  some  advantages;  the  limited  list  of  therapeutic 
means  used  in  antiquity  permitted  an  accurate  verification  of 
their  utility  or  inutility;  and  the  credit  in  which  sublingual 
bleeding  was  held  during  so  many  centuries,  would  seem  to 
justify  a  re-trial  of  the  plan,  as  Aran  has  done. 

The  immediate  or  direct  abstraction  of  blood  by  scarification 
of  the  tonsil  is  commended  by  all  recent  authority.  As  a 
rational  procedure  it  commends  itself  in  this,  that  thus  the 
engorged  surface  is  emptied  of  its  blood,  and  the  several  vessels 
do  not  admit  of  the  return  of  the  blood  and  its  passage  through 
them.  To  scarify  properly,  the  surgeon's  bistoury  or  scalpel 
should  have  an  edge  that  is  faithfully  sharp;  the  incisions  made 
should  be  superficial,  transverse  in  direction,  and  numerous. 
And  to  promote  the  bleeding  afterwards,  the  patient  should 
gargle  with  tepid  water,  that  has  been  made  alkaline  with  car- 
bonate of  potassium  or  carbonate  of  sodium,  or  with  tepid  lime- 
water.     If  the  scarification  be  well  done,  it  need  not  be  repeated. 

After  the  local  depletion  has  thus  been  effectively  done,  to 
favor  contraction  and  retraction  of  the  inflamed  structures, 
astringent  gargles  should  be  prescribed;  and,  as  agents  of  this 
class,  one  may  select  the  mineral  or  vegetable  astringents:  for 
example,  alum  or  tannin.  And  as  adjuvants  the  topical  use  of 
tinctura  iodini  composita,  tinctura  gallse,  or  tinctura  benzoini 
compositamay  be  resorted  to.  In  those  cases  of  abnormal  dis- 
position of  the  environing  pharyngeal  muscleSj  in  which  the 
tonsil  is  begirt  as  with  a  constricting  band,  the  localized  and 
isolated  use  of  the  latter  remedies  is  better  than  the  diffused 
application,  as  happens  in  the  use  of  gargles;  since  the  latter, 
acting  on  the  parts  around,  constrict  and  congest  the  in-walled 
tonsil;  but  if  the  latter  alone  be  touched,  the  full  effect  of  the 
remedy  will  be  obtained.  The  patient  should  also  be  given  frag- 
ments of  ice,  by  which  the  heat  of  tlie  mouth  will  be  lowered. 

To  these  means  saline  cathartics  sliould  be  conjoined. 

The  prompt  and  judicious  use  of  the  procedures  and  remedies 
mentioned  will,  sometimes,  stay  the  disease  midway  in  its  course, 
and  secure  the  desired  termination  by  resolution;  but  quite  as 
often  these  means  do  not  arrest  tlie  progress  of  the  inflammation; 
it  then  proceeds  to  suppuration. 

Inflammation  rarely  limits  itself  to  an  isolated  structure,  or  an 
organ;  it  commonly  overleaps  the  artificial  barriers  \vlncli  have 


696  TONSIL. 

been  set  for  its  isolation  by  the  classifying  hand  of  the  nosologist, 
and  this  often  occurs  in  affections  of  the  tonsils;  inflammation 
may  appear  in  it  primarily,  or  it  may  extend  to  it  secondarily 
from  contiguous  structure;  and  hence,  when  the  event  is  sup- 
puration, the  pus,  according  to  the  location  of  the  inflammation, 
may  be  tonsillar,  or  peritonsillar,  in  site.  Pus  is  oftenest  devel- 
oped in  the  connective  tissue  which  lines  the  niche  in  which  the 
tonsil  lies;  and  this  is  most  frequent  above  or  behind;  and,  as 
previously  remarked,  the  focus  of  pus  is  discoverable  by  touch 
rather  than  by  sight.  Free  scarification,  opportunely  done,  often 
prevents  suppuration;  but  this  failing,  and  pus  forming,  the  lat- 
ter must  be  liberated  by  incision.  If  the  purulent  material  be 
near  the  surface,  it  is  reached  by  a  slight  cut  with  the  lancing 
instrument.  The  opening  may  be  made  with  a  scalpel  or  bis- 
toury; and  if  the  hand  be  inexperienced,  the  incising  blade  ma}' 
be  wrapped  with  cloth,  so  that  only  a  small  portion  of  the 
pointed  part  will  remain  exposed;  such  protection,  however, 
to  a  disciplined  hand  would  prove  but  an  impediment.  If  the 
pus  be  deep,  then  a  shallow  incision  may  be  made  over  it,  and 
afterwards,  a  blunt  dissector  or  large  l)lunt  probe  may  be  ])ushed 
through  the  remaining  wall.  But  if  the  pus  lies  behind  and 
adjacent  to  the  tonsil,  care  must  be  used  in  opening;  since  the 
internal  carotid  artery  lies  external  to  the  pus,  being  only 
separated  from  it  by  the  superior  constrictor  muscle  and  the 
pharyngeal  fascia.  Pus  in  this  situation  has  perforated  this  thin 
wall,  and,  b}'  erosion,  opened  the  arter}''  and  caused  hreraorrhage, 
speedily  fatal,  as  was  ob.served  by  Grisolle.  If  it  becomes  neces- 
sary to  liberate  with  the  lance  }>us  seated  over  the  vessel,  the 
point  of  the  instrument  should  be  directed  rather  towards  the 
posterior  pharyngeal  wall,  than  towards  the  side;  the  bistoury 
should  pass  backwards  and  not  laterally.  Thus  doing,  the  fatal 
work  of  opening  the  vessel  which  has  been  reported  by  Beclard 
and  others,  will  be  avoided. 

Some  writers  advise  against  opening  the  collection  of  pus, 
and  prefer  to  allow  it  to  burst  spontaneously;  such  is  the  teach- 
ing of  Stromeyer,  who  claims  that  lancing  the  suppurated  tonsil 
awakens  new  inflammatory  and  additional  suppurative  action. 
It  is  true  that  after  one  collection  of  pus,  another  ma}'  appear 
later;  yet  this  second  one  was  in  process  of  formation,  and  if  the 
first  had  not  been  opened,  the  two  would  finally  have  fused 
together;  but  opening  the  two  as  they  respectively  mature, 
greatly  limits  the  suppurative  process ;  and  materially  lessens  the 
patient's  pain. 


HYPERTROPHY    OF    THE    TONSIL.  697 

When  the  pus  Las  exit,  the  subjective  accompaniments  of 
pain,  discomfort  and  functional  impairment,  at  once  lessen  and 
gradually  disappear.  As  a  detersive  gargle  to  aid  in  the  removal 
of  the  excreta,  some  alkaline  solution,  as  aqua  calcis,  may  be 
used.  This  will  be  rendered  more  agreeable  to  the  patient  by 
the  addition  of  menthol  or  mint-water;  mint-water,  to  which  car- 
bonate of  potassium  has  been  added,  will  act  well.  By  treatment 
as  described,  the  purulent  content  will  be  eliminated,  the  hollow 
breach  will  close,  and,  afterwards,  the  tonsil  will  present  an 
irregular  surface. 

There  are  patients,  usually  adults  in  the  prime  of  life,  who 
are  the  subjects  of  recurring  attacks  of  suppurative  tonsillitis, 
the  disease  occurring  annually,  or  at  longer  intervals.  In  such 
persons  an  attempt  may  be  made  to  arrest  the  disease  at  its  onset, 
and  for  this  purpose,  Bell,  in  1842,  announced  that  gum  guaiac, 
given  internally,  is  an  excellent  remedy,  and  at  the  same  time 
the  patient  should  be  purged.  Herpin,  of  Geneva,  cauterized 
the  sufface  of  the  tonsil  with  pure  nitrate  of  silver.  Reel-Ogez, 
as  abortive  treatment,  advises  to  gargle  hourly  with  the  subjoined 
solution: — 

R.     Pluinbi  Acetatis gr.  v  ad.  x 

Gum  Acacise giv 

Syrupi ^ss 

Aqu8e Ey 

Misce. 

These,  and  other  local  remedies,  are  inferior  to  simple  scarifi- 
cation of  the  surface  of  the  tonsil;  if  this  be  done  early,  and  well 
done,  the  disease  may  often  be  arrested  in  its  incipience,  and  reso- 
lution obtained. 

Hypertrophy  of  the  Tonsil. — The  tonsil  may  be  abnormally 
enlarged  as  a  permanent  condition.  The  structural  conditions 
present  consist  mainly  of  a  multiplication  of  the  component  ele- 
ments; the  stroma  of  connective  tissue,  intervening  between  the 
lacunps  and  follicles,  is  thickened  and  hardened,  so  that  it  resists 
and  creaks  under  the  incising  blade.  Though  hard,  the  structure 
is  usually  more  friable  than  normal  tonsillar  tissue.  In  the 
enlarged  lacunae  are  lodged  masses  of  epithelial  excreta;  and 
sometimes  calcareous  concretions  are  found  there.  The  tonsil's 
volume  is  commonly  augmented  to  two  or  three  times  its  normal 
size,  and,  exceptionally,  this  may  be  much  exceeded.  The  color 
may  be  normal;  often  it  is  pale  and  bloodless  in  hue.  The  sur- 
45 


698  TONSIL. 

face  may  be  smooth,  or  it  may  be  rough,  lobulated  and  pitted  with 
depressions.  As  a  rule,  the  enlarged  tonsil  is  painless;  more 
rarely,  pain  can  be  awakened  by  pressure. 

When  the  tonsils  are  much  hypertrophied,  they  displace  the 
palatal  veil,  so  that  this  part,  partly  or  entirely  closes  the  choanae. 
They  touch  each  other  in  the  median  line,  or  so  nearly  do  so,  that 
a  small  space  remains  for  the  passage  of  air  and  food.  Sometimes, 
the  adherent  pharyngeal  arches  repress  the  tonsils,  and  then  their 
encroachment  upon  the  pharynx  is  much  lessened. 

Tonsillar  hypertrophy  may  impair  audition  and  plionation, 
impede  respiration  and  deform  the  chest,  and  cause  catarrhal 
trouble  in  the  nostrils,  phar3mx  and  air-passages. 

Disturbance  of  hearing,  for  a  long  time,  was  thought  to  depend 
on  the  closure  of  the  openings  of  the  Eustachian  tubes.  In  a 
study  of  the  subject,  Harvey,  Crisp,  and  others,  deny  that  deaf- 
ness is  thus  caused;  they  refer  it  to  lessening  of  the  calibre  of  the 
tube  through  tumefaction  and  swelling  of  its  lining  membrane. 
In  fact,  the  direction  of  the  enlargement  of  the  tonsil  is  rather 
away  from,  than  towards,  the  tube;  and  the  effect  of  it  is  to  pull 
open  the  mouth  of  the  tube.  But,  as  the  tube's  lining  is  thickened 
by  extension  of  the  tonsillar  trouble,  whatever  lessens  the  latter, 
improves  the  hearing.  And  the  observation  of  this  fact  was  the 
secret  of  the  successful  career  of  an  eminent  charlatan,  St.  John 
Long,  who  some  years  ago  enjoyed,  in  London,  a  transient  era  of 
prosperity  in  the  cure  of  deafness.  His  treatment  consisted  in 
the  excision  of  the  tonsils,  and  thus,  it  is  said,  he  cured  or  relieved 
many  cases  of  deafness.  But  as  many  cases  of  deafness  do  not 
originate  from  such  cause,  the  imjnense  practice  of  this  empiric 
soon  fell  off,  and  he  was  remanded  to  the  obscurity  from  which 
he  had  lately  emerged. 

The  obstruction  of  the  choanse  interferes  with  the  normal  de- 
velopment of  the  vocal  sounds;  the  patient  speaks  with  a  nasal 
tone;  or  rather,  the  voice  seems  muffled. 

The  enlarged  tonsils  obstruct  the  entrance  of  the  air  to  the 
lungs,  and  thus  respiration  is  seriously  embarrassed.  The  child 
which  is  tlie  subject  of  such  hypertrophy,  ceases  to  breathe 
through  the  nose,  in  consequence  of  the  labor  which  nasal  respi- 
ration demands;  the  child  breathes  through  its  partly  opened 
mouth,  and  in  so  doing,  it  presents  a  picture  of  mental  imbecility 
and  forbidding  stupidit3^  It  is,  however,  during  sleep  that  the 
enlarged  tonsils  specially  obstruct  breathing;  the  tongue  then, 
particularly  in  the  dorsal  position,  presses  the  epiglottis  backwards 


HYPERTROPHY    OF    THE    TONSIL.  699 

and  downwards,  so  as  to  nearly  close  the  glottis;  in  this  closure 
the  large  tonsils  concur,  both  by  their  volume  and  weight.  Such 
sleep  approaches  the  nature  of  profound  angesthetic  narcotism, 
and  the  analogy  is  close  when  one  records  that  the  little  sleeper 
is  often  congested  in  its  face,  and  slightly  cyanosed,  owing  to  the 
want  of  a  proper  amount  of  air.  The  guttural  rhoncus  of  the 
inspiratory  effort  and  tlie  occasional  closure  of  the  mouth  and 
temporary  suspension  of  breathing,  often  alarm  the  parent  or 
nurse.  And  so  great  has  been  the  parental  anxiety,  that  it  has 
been  recorded  by  Roger  that  the  mother  of  such  a  child  was 
accustomed  to  nightly  watch  her  infant,  and  with  her  hand  press 
the  chin  downwards,  so  as  to  prevent  the  mouth  from  closing. 

This  unusual  respiratory  effort,  when  prolonged  in  the  child,, 
finally  induces  a  deformity  of  the  thorax.  In  1828,  Dupuytren 
called  attention  to  the  frequent  coincidence  of  deformity  of  the 
chest-wall  with  enlarged  tonsils.  He  merely  noted  the  concur- 
rence of,  and  not  the  causal  connection  between,  the  two  condi- 
tions. 

Warren,  of  Boston,  in  1838,  published  his  observation  that 
enlarged  tonsils  cause  deformity  of  the  chest.  And,  near  the 
same  time,  similar  observations  were  made  by  Coulson,  of  London. 

Moity,  in  1858,  announced  that  enlarged  tonsils  impair  hear- 
ing, taste,  and  dwarf  the  intellect;  the  retarded  flow  of  blood 
to  the  brain  interfering  with  its  normal  evolution,  mentality  is 
thus  abridged. 

Most  writers  upon  this  subject  describe  two  classes  of  thoracic 
deformity  associated  with  tonsillar  deformity:  one  in  which  the 
subject  is  rachitic,  and  the  other  in  which  this  constitutional  dis- 
ease does  not  exist. 

In  these  cases  of  perverted  thoracic  form,  the  deformity  con- 
cerns chiefly  the  lower  part  of  the  chest;  the  upper  part  retains 
its  normal  contour.  In  the  lower  half  of  the  chest  the  ribs  are 
incurved;  and  this  depression  is  greatest  near  the  middle  portion 
of  the  ribs.  The  sternum  likewise  shares  in  the  deformity ;  the 
lower  portion  is  deviated  inwards,  while  the  upper  part  remains 
in  normal  position.  The  thoracic  deformity  due  to  rachitis  differs 
from  that  of  pure  tonsillar  hypertrophy;  in  rachitis  the  costal 
cartilages  are  unduly  prominent,  while  the  ribs  are  sunken  at  the 
sides  of  the  chest,  so  as  to  form  two  vertical  gutters,  one  on  each 
side,  extending  through  the  entire  height  of  the  chest. 

Different  explanations  of  the  fhoracic  deformity  from  hyper- 
trophied  tonsils  have  been  offered;    Robert  thinks  that  it  arises 


700  TONSIL. 

from  the  diminished  tension  of  tlie  air  contained  in  the  chest 
during  the  effort  of  inspiration,  the  weight  of  the  external  air 
forces  inwards  the  lower  part  of  the  sides  of  the  chest.  Tliis 
explanation  does  not  account  for  the  upper  jiart  of  the  thorax 
remaining  in  situ,  though  it  is  acted  equally  on  by  the  atmos- 
pheric pressure. 

Lambron,  who  has  ])ublislied  an  exhaustive  monograph  on 
the  tonsil,  refers  the  incurvation  to  the  action  of  the  diaphragm. 
In  ordinary  breathing,  the  inspiratory  effort  is  made  by  tlie  dia- 
})hragni;  and  as  this  muscle  is  inserted  into  the  ribs  forming  the 
lower  half  of  the  chest,  the  deformity  is  limited  to  the  lower 
portion  of  the  chest.  A  favoring  condition  which  the  author 
suggests,  is  the  greater  mobility  of  the  lower  ribs,  which  becomes 
especially  conspicuous,  when  the  normal  chest  is  inflated  by  a  deep 
inspiratory  effort.  Emphysema  of  the  lungs  is  often  associated 
with  the  tonsillar  and  costal  deformity;  and  it  is  correlated  to 
the  incurvation  of  the  lower  part  of  the  cliest,  since  the  pulmo- 
nary tissue,  by  its  expansion  above,  compensates  for  the  dimin- 
ished cell-room  below.  Again,  the  attending  mobility  of  the 
lower  part  of  the  tliorax,  gives  it  some  immunity  against  those 
diseases  which  find  a  starting-point  in  the  summits  or  the  upper 
parts  of  the  lungs. 

The  tonsil  is  sometimes  enlarged  through  constitutional  syph- 
ilis; an  instance  of  this  was  seen  by  the  writer,  in  wliich  a 
recovery  was  obtained  through  excision  of  tlie  tonsil  and  anti- 
sypiiilitic  treatment. 

Treaiment. — As  treatment,  one  may  resort  to  means  which  will 
oppose  or  correct  the  predisposition  to  tonsillar  enlargement: 
also  means  may  be  resorted  to  which  applied  to  the  enlarged 
tonsils,  cause  reduction  of  their  volume;  and  finally,  the  attempts 
in  these  directions  proving  fruitless,  the  part  should  be  removed. 

The  scrofulous  or  tubercular  diathesis  which  often  accomj)a- 
nies  the  hypertrophy,  should  be  combated  by  means  of  iodide  of 
potassium,  iron  and  arsenic.  Sulphur  baths,  and  the  local  use 
of  sulphureted  water  in  the  form  of  douche  directed  on  the  ton- 
sil, have  acted  curatively  against  its  enlargement.  The  remedial 
efficacy  of  this  treatment  will  be  especially  manifest  in  those  who 
are  likewise  tlie  subjects  of  herpetic  or  eczematous  disease. 

Patient  effort  in  the  use  of  topical  remedies  will  lessen  the 
enlarged  tonsil ;  of  these  means,  the  best  are  those  which  have  an 
astringent  action.  One  of  the  most  effective  is  a  combination  of 
iodine  and  galls,  in  the  following  mixture: — 


TONSILLOTOMY.  701 

1^.  Tr.  lodini  compositee. 

Tr.  Gallse aa  gi 

Misce. 

Let  this  be  applied  with  a  brush  to  the  tonsil,  once  daily.  This 
compound  is  better  than  pure  tincture  of  iodine,  which  is  often 
used,  topically.  Also,  one  may  apply  to  the  part  a  saturated 
solution  of  glycerine  and  tannin.  Astringent  gargles  containing 
alum,  zinc  or  borax,  if  diligently  used,  may  have  some  agency 
in  lessening  the  volume  of  the  tonsil.  It  is  probable  that  friction 
or  massage  of  the  tonsils  would  favor  their  reduction;  the  rebel- 
lious reflex  movements  of  the  parts,  which  at  first  would  be 
awakened,  w^ould  soon  disappear.  As  a  means  to  curtail  the 
-volume  of  the  tonsils,  in  1869,  Ruppaner  applied  to  them  the 
following  mixture:  caustic  soda,  caustic  potash,  and  caustic  lime, 
in  equal  parts,  were  moistened  with  alcohol  and  applied  with  a 
glass  rod  to  the  tonsil.  From  six  to  fourteen  applications  were 
needed  to  reduce  to  normal  form.  With  such  treatment,  Rup- 
paner  reports  that  he  cured  one  hundred  and  twenty-three  cases. 
If  the  general  and  local  treatment  here  mentioned  fail  in  its  pur-, 
pose,  the  part  should  be  excised. 

Tonsillotoviy,  Amygdalotomy,  or  Excision  of  the  Tonsils. — The 
chirurgus  or  surgeon  of  ancient  Rome  excised  the  tonsils;  says 
Celsus:  ''When  the  tonsils  have,  through  inflammation,  become 
indurated,  and  they  are  covered  with  a  thin  coating,  one  should 
thrust  the  finger  in  around  them  and  thus  pluck  them  out;  but 
if  they  cannot  thus  be  loosened,  it  is  proper  to  catch  them  with  a 
hook  and  cut  them  off"  (hamulo  excipere  et  scalpello  excidere)^  Near 
the  same  period,  ^tius,  who  lived  fifty-four  years  after  Christ, 
directed  to  remove  the  prominent  part  of  the  hypertrophied 
tonsil;  that  is,  about  half  of  it;  for  those  who  excise  the  entire 
tonsil,  remove  also  sound  structures,  and  cause  great  bleeding. 
Paul  of  iEgina  counseled  the  removal  of  the  tonsils ;  and  his- 
method  was  followed  by  Albucasis  and  the  Arabian  physicians; 
their  method  was  as  follows  :  The  tonsil  is  first  to  be  caught  with 
a  dissecting  hook,  and  to  be  lifted  up  as  much  as  possible  with- 
out acting  on  the  surrounding  parts;  then  the  tonsil  is  to  be 
removed  wholly  from  the  cavity  in  which  it  is  contained  by 
means  of  a  bistoury,  which  is  held  in  the  hand,  and  corresponds 
in  its  form  to  the  curvature  of  the  tongue.  Albucasis  feared 
when  the  base  of  the  tonsil  was  large,  that  in  its  removal,  thero 
might  occur  a  liEemorrhage  which  would  be  difficult  to  control. 

In  the  middle  ages,  tonsillotomy,  sharing  the  fate  of  the  liga- 


702  TONSIL. 

tul"e,  fell  into  disuse;  and  in  the  renaissance  of  medicine,  the 
operation  was  approached  with  timidity  and  distrust.  Ambrose 
Pare  mentions  ligation  of  the  tonsils;  but  headvised  tracheotomy 
in  patients  menaced  by  suffocation  by  enlarged  tonsils.  Guille- 
meau,  pupil  of  Part^,  did  not  favor  tracheotomy,  but  he  advised 
the  ligation  or  excision  of  the  enlarged  tonsils,  of  which  the  base 
is  small.  He  advised  care  in  the  selection  of  the  cases  in  which 
the  tonsils  should  be  removed.  Soon  afterwards,  Severini,  of 
Naples,  in  an  epidemic  in  which  the  tonsils  were  affected,  cau- 
terized and  excised  these  parts.  Dionis,  who  wrote  in  1G72, 
opjtosed  excision,  eradication,  and  other  means  employed  to 
destroy  the  tonsils;  he  thought  the  parts  had  some  functional 
importance,  and  should  not  be  removed.  Portal  adopted  this 
advice.  Junker  favors  partial  excision;  and  he  prefers  to  do  this 
with  tlie  ligature.  Heister  opposes  excision  as  barbarous  and 
difficult;  he  prefers  to  remove  by  means  of  cauterization.  He 
speaks  of  the  danger  of  the  excised  tonsil  falling  into  the  throat. 
Sharp  claims  tonsillar  ligation  as  an  English  procedure;  and  he 
believes  that,  thus  operating,  the  hemorrhage  which  may  follow 
excision  can  be  avoided.  In  1734,  Wiseman,  in  writing  on 
removal  of  the  tonsil,  considers  cauterization,  actual  or  j)otential, 
as  the  simplest  method.  In  cases  in  which  he  did  excision,  he 
first  passed  a  tliread  tli rough  the  tonsil,  and  then,  cutting  behind 
the  thread,  he  guarded  against  the  exei.^ed  part  falling  into  the 
glottis:  a  fatal  accident  which  occurred  to  Moscati,  near  this  time. 
As  a  safer  plan,  Moscati  afterwards  crucially  divided  the  tonsil, 
and  when  suppuration  had  ensued,  he  excised  each  fragmentary 
C[uarter  that  remained.  Museux,  who  invented  the  toothed 
forceps  which  bears  his  name,  used  this  instrument  to  fix  the 
tonsil,  which  he  excised  with  curved  scissors.  Early  in  this  cen- 
tury, a  rude  tonsillotome  was  devised;  the  tonsil,  engaged  in  the 
end  of  a  furcated  staff,  and  held  tliere  with  a  tenaculum,  was 
excised  with  a  blade  tliat  passed  through  the  ensheathing 
furcated  staff. 

In  the  early  part  of  this  century,  Samuel  Cooper  preferred  the 
use  of  the  ligature  to  excision.  Dupuytren  used  toothed  fixing 
forceps,  and  he  cut  off  tlie  tonsil  with  a  bistoury,  of  wliich  the 
greater  part  of  the  blade  had  been  wrapj)ed  in  a  bandage.  In 
1840,  Pappenheim  heralded  an  innovation,  in' which  he  intro- 
duced his  left  hand  in  the  mouth,  and,  having  seized  the  tonsil 
witli  the  thumb  and  finger,  and  then  pressing  down  tlie  tongue 
with   the  remaining   fingers,  he  cut  off  the  uplifted  part  with 


TONSILLOTOMY.  703 

curved  scissors,  held  in  the  right  hand.  Dieffenbach  caught  the 
tonsil  with  a  hook  and  excised  with  a  knife.  Synie  and  Liston, 
leaders  in  English  surgery,  operated  with  a  hook  and  a  bistoury, 
of  which  the  greater  part  of  the  blade  was  wrapped  in  cloth.  In 
1858,  Larghi,  of  Turin,  revived  the  ancient  method  of  Celsus, 
which  might  be  named  the  ungual  method;  with  his  finger  nails 
he  detached  the  tonsil  from  above  downwards;  and  he  pronounces 
the  plan  an  easy  one.  As  the  majority  of  the  cases  requiring 
tonsillar  removal  are  in  children,  the  plan  of  introducing  the 
fingers  into  the  mouth  would  imperil  the  operator  quite  as  much 
as  the  jDatient;  and  between  the  two,  it  is  probable  that  liis  own 
wounds  would  be  the  greater  unless  pains  were  taken  to  hold  the 
jaws  ajar. 

Interstitial  cauterization  done  by  means  of  chloride  of  zinc, 
and  much  used  by  Maisonneuve,  was  tried  in  the  enlarged  tonsil; 
the  difficulty  of  reaching  the  part,  and  the  dangerous  possibility 
of  some  of  the  escharotic  material  escaping  into  the  throat,  have 
caused  this  method,  as  well  as  others  which  consist  in  the  use  of 
potential  caustics,  to  be  abandoned. 

Ligation,  which  has  been  advocated  by  many  surgeons, 
besides  being  a  difficult  procedure,  exposes  the  patient  to  the 
nauseous  condition,  of  swallowing  much  of  the  septic  matter  and 
gangrenous  material  which  arise  from  this  plan  of  tonsillar 
removal;  and  such  toxic  materials  may  descend  through  the 
trachea  to  the  lungs  and  awaken  disease  there.  To  avoid  these 
accidents,  the  constricting  chain  or  wire  of  the  ecraseur  has  been 
passed  through  and  around  the  tonsil,  and  the  separation  been 
done  at  once;  but  ligation,  whether  done  instantaneously  or 
tardily,  is  no  longer  employed  as  means  of  tonsillar  removal. 

Delay  in  doing  the  work  in  the  child  has  been  counseled  with 
the  hope  that  the  tonsils  might  become  of  less  volume,  when  the 
subject  reaches  puberty;  such  hope  is  but  exceptionally  realized ; 
and,  meantime,  the  delay  may  permit  thoracic  malformation  to 
arise  as  the  result  of  such  hypertrophy.  Besides  the  vicious 
conformation  of  the  chest,  and  its  attendant  ills,  which  project  a 
shadow  in  which  the  patient  must  ever  afterwards  walk,  the 
young  patient's  existence  is  peculiarly  menaced,  should  he 
become  the  subject  of  diphtheritic  disease  of  the  throat;  for  then, 
a  slight  addition  to  the  volume  of  the  tonsils  may  prevent  the 
entrance  of  air  to  the  lungs,  and  cause  suffocation.  Here  the 
early  removal  of  the  enlarged  tonsils  in  the  child  is  a  prophylactic 
measure  against  such  casualty. 


704  TONSIL. 

Ill  regard  to  the  age  at  which  the  operation  should  be  done, 
Guersant,  who  is  authority  in  tliis  matter,  counsels  that  it  should 
be  done  early;  he  operated  often  in  children  from  eighteen  to 
twenty-four  montlis  of  age;  if  done  early,  there  is  less  danger  of 
lurmorrhage.  In  one  thousand  children  operated  on,  he  never 
saw  hsemorrhage;  while  in  adults,  it  occurred  in  one-fourth  of 
the  cases.  St.  Germain  would  fix  as  time  for  the  operation  tlic 
a.o-e  between  two  and  eight  years;  though  so  excellent  a  surgeon 
w^ould,  no  doubt,  have  done  the  operation  at  a  later  age,  sliould 
the  exigency  have  arisen.  The  writer,  whose  experience  in  this 
matter  has  not  been  limited,  deems  the  period  when  the  child 
has  reached  the  age  of  reason,  a  more  satisfactory  time  for  the 
work  than  that  of  earlier  infancy.  In  his  surgical  experience  he 
recalls  no  operative  work  that  was  more  difficult  than  a  few 
cases  of  tonsillar  excision  in  the  infant.  If  the  removal  be  done 
without  anresthesia,  the  work  of  immobilizing  the  patient  requires 
a  restraining  force  of  assistants,  and  much  boisterous  effort;  in 
fact,  it  is  a  struggle  or  a  battle  from  which  the  operator  would 
retreat  could  he  do  so  with  decorum,  and  especially  so,  where  the 
infant  has  parental  reenforcement;  viz.,  a  father  and  mother  who, 
though  feigning  forgiveness,  rarely  pardon  the  rude  w'ay  in  which 
the  victory  over  their  offspring  is  won;  and  in  such  cases  the 
requital  which  is  made  for  the  services  has  but  a  tliin  gilding  of 
gratitude. 

To  render  the  task  an  easier  one,  the  child  may  be  anaesthet- 
ized; yet  this  aid  brmgs  the  serious  inconvenience  that  the  throat 
is  so  nearly  closed  that  when  narcotized,  the  child's  life  is  imper- 
iled by  suffocation;  the  base  of  the  tongue  and  the  tonsils  falling 
together  quite  close  the  pharynx.  Hence,  during  the  work,  the 
tongue  must  be  continuously  withdrawn  from  the  mouth  with 
appropriate  forceps.  Besides,  when  the  patient  is  anaesthetized, 
there  is  danger  of  blood  entering  the  larynx  and  causing  asphyxia. 
The  writer's  experience  leads  him  to  operate  without  anaesthesia; 
and  not  unfrequently,  the  child  may  be  beguiled  into  the  work, 
and  one  tonsil  may  be  removed  before  he  becomes  aware  of  what 
is  intended,  and  ere  the  surprise  which  the  w^ork  has  awakened 
has  fully  passed,  the  remaining  tonsil  may  often  be  removed. 

There  are  two  methods  of  tonsillotoujy,  which  have  their 
respective  advocates:  excision  with  a  scalpel  or  bistoury,  and 
excision  with  a  special  instrument  named  tonsillotome.or  tonsillar 
guillotine. 

To  excise  with  a  blunt-pointed  scalpel,  or  bistoury,  or  blunt 


TOXSILLOTOMY.  705 

scissors,  there  is  required  a  pair  of  toothed  forceps,  or  a  long- 
handled  tenaculum;  aho  a  tongue-depressor,  intermaxillary 
gag,  and  sponges.  If  a  bistoury  be  used,  all  of  the  blade,  except 
an  inch  and  a  half  from  the  point,  should  be  covered  with  adhe- 
sive plaster,  or  a  bandage  to  guard  against  any  unnecessary 
cutting  of  the  surgeon  or  patient.  The  tonsils  having  been 
cocainized,  and  the  patient  being  a  tractable  subject,  the  work  is 
done  as  follows:  one  assistant  standing  behind  steadies  and 
supports  the  head;  another  aid  is  ready  to  hold  the  hands,  should 
the  patient  be  timid,  and  a  third  may  be  needed  to  depress  the 
tongue.  The  patient's  right  tonsil  having  been  seized  with  the 
toothed  forceps,  is  to  be  drawn  inwards,  so  that  its  base  or  pedicle 
will  be  accessible  to  the  knife;  tlien  with  the  cutting  instrument, 
the  tonsil  is  to  be  severed  from  below  upwards,  by  sawing  move- 
ments. Should  the  tongue  fall  backwards,  it  must  be  pressed 
downwards  and  forwards  with  a  depressor;  this  act  is  often 
unnecessary,  since,  as  soon  as  the  tonsil  is  caught  with  the  tenac- 
ulum, or  toothed  forceps,  it  can  easily  be  brought  into  view.  The 
upward  cutting  is  to  be  so  done  that  tlie  palatal  veil  and  arclies 
will  not  be  wounded. 

Should  the  patient  be  a  rebellious  child  who  has  not  reached 
the  age  of  reason,  or  whose  fears  have  temporarily  bereft  him  of 
reason,  then  a  small  troop  of  assistants,  says  St.  Germain,  will  be 
needed  to  coerce  him  into  the  necessary  quiet;  one  should  hold 
his  head;  a  second  should  hold  the  arms,  and  a  third  may  hold 
the  legs,  and  a  fourth  may  depress  the  tongue,  and  also  sponge 
out  the  throat,  as  rec|uired.  All  the  aids  except  the  last,  stand  at 
the  side,  so  as  not  to  be  in  the  way  of  the  work.  Nearly  all  this 
force  of  assistants  (of  wliich  St.  Germain  doubles  the  number 
here  mentioned)  may  be  dispensed  with,  if  the  child  beanjesthet- 
ized;  and  from  the  writer's  experience,  the  restraint  can  be  made 
without  ansesthesia  by  two  aids,  namely,  one  can  hold  the  child 
in  his  lap,  and  with  one  arm  hold,  support  and  steady  tlie  head, 
and  with  the  other  he  can  hold  the  hands,  while  with  his  knees 
he  clasps  and  fixes  the  child's  legs;  the  second  assistant  depresses 
the  tongue  and  wipes  out  the  throat  when  needed.  And  a  third 
aid  is  sometimes  required  to  hold  in  place  the  interdental  dilator. 
The  patient,  finding  that  his  efforts  of  resistance  are  overcome  at 
every  point,  finishes  by  firmly  and  defiantly  shutting  his  mouth 
and  clinching  his  teeth.  To  meet  this  some  address  is  needed; 
if  the  nose  be  held,  in  the  moment  when  the  mouth  is  opened,  a 
spatula  may  be  thrust  between  the  teeth,  and,  being  pushed  back 


706  TONSIL. 

to  the  throat,  the  retching  movement  thus  induced  fully  opens 
the  jaws,  when  some  body,  as  a  wedge-sliaped  ])iece  of  wood,  may 
be  inserted  between  the  molar  teeth,  and  the  closure  of  tlie  jaws 
tlius  prevented.  At  this  point,  the  surgeon  can  proceed  with  the 
use  of  his  bistoury,  and  complete  his  task  at  his  leisure. 

Early  in  his  professional  career  the  writer  did  the  excision 
with  a  i)air  of  large  curved  scissors,  an  instrument  which  Cloquet 
prefers  for  the  woi'k.  To  use  the  scissors,  the  right  tonsil  sliould 
first  be  cauglit  with  the  fixing  tenaculum,  and  being  properly 
lifted  from  its  niche,  the  cutting  is  done  with  one  stroke  of  the 
scissors.  In  using  the  scissors  the  o[)erator  should  be  careful  to 
have  tlie  tonsil  well  included  between  the  blades  before  they  are 
closed.  As  said,  in  the  use  of  either  the  bistoury  or  the  scissors, 
the  patient's  riglit  tonsil  should  first  be  removed,  since,  for  the 
right-handed  operator,  this  is  tlie  more  difiicult  act,  because  the 
hands  must  be  crossed  in  the  work.  The  left  one  is  next  to  be 
seized  and  removed;  and  as  the  patient  is  restive  from  what  has 
been  done,  and  there  is  some  bleeding,  it  is  well  that  the  work 
concludes  with  the  easier  act. 

Whether  the  bistoury  or  scissors  do  the  cutting,  the  operation 
will  fail  of  its  purpose,  if  there  be  not  excised  one-half  of  the 
tonsil;  so  that  the  remaining  stump  will  scarcely  reach  to  the 
level  of  the  bounding  arches. 

As  the  removal  of  the  tonsils  by  the  bistoury  or  scissors 
demands  some  mechanical  skill,  which  must  be  acquired  by  repe- 
tition of  the  work,  invention  has  sought  to  furnish  the  operator 
with  an  instrument  which  may  do  the  excision  with  little  or  no 
manual  dexterity.  To  do  this,  an  instrument  named  tonsillotome, 
of  various  forms,  has  been  devised.  The  original  model  of  the 
tonsillotome  was  conceived  and  constructed  in  America  by 
Fahnestock.  Several  modifications  and  improvements  of  this 
instrument  have  since  appeared;  in  some  the  work  is  done  by 
pushing,  guillotine-like,  or  by  ])ulling  the  cutting  blade.  The 
tonsillotome,  in  the  main,  consists  of  three  parts:  a  staff"  which 
ends  in  an  elliptical  ring  of  which  the  inner  border  has  a  cutting 
edge;  a  second  staff  similar  to  the  first,  of  which  the  ring  has  a 
cutting  edge:  and  the  two  staffs  are  so  attached  together  that  the 
second  can  be  moved  on  the  first;  and,  as  this  is  done,  the  tonsil, 
which  is  included  in  the  rings,  is  cut  off.  And  on  the  double 
staff  there  is  fixed  a  transfixor  and  elevator,  which  has  a  barbed 
end  like  a  fisherman's  gig.  The  instrument  is  a  combination  of 
most  ingenious  devices,  awakening  admiration  of  the  numerous 


TONSILLOTOMY.  707 

hands  which  have  shared  in  the  creation  of  its  final,  present 
form;  and  not  the  least  curious  is  the  arrow-pointed  transfixor, 
which  can  be  so  adjusted  as  to  lift  the  tonsil  to  any  elevation 
above  the  cutting  edges  which  may  be  needed. 

Though  this  tonsillotome  works  so  nearly  automatically,  yet 
some  advice  for  its  use  is  needed  for  the  inexperienced.  The 
cutting  edges  should  be  very  sharp.  The  containing  ring  should 
not  include  any  part  of  the  adjacent  muscular  arches,  the  palatal 
veil,  or  the  uvula.  The  original  instrument  was  worked  by  both 
hands;  the  present  one  is  worked  with  one 'hand;  or  if  the  left 
one  aids,  it  is  merely  in  steadying  the  instrument.  In  doing  the 
work  with  one  hand,  the  error  is  sometimes  made  of  withdrawing 
the  instrument  as  the  cutting  is  being  done;  this  must  be  studi- 
ously avoided  by  holding  the  outer  staff  in  place,  while  the 
inner  is  moved  inwards  or  outwards,  according  as  the  cutting  is 
done  by  pulling  (the  usual  way),  or  pushing;  that  is,  one  blade 
must  be  held  in  place  while  the  other  does  the  excision.  If  both 
be  drawn  together,  the  tonsil  will  escape  from  the  grasp  and  much 
of  it  will  be  left  behind.  And  the  same  will  result  if  the  cutting 
edge  be  dull. 

No  instrument  is  more  difficult  to  be  kept  in  good  working 
condition  than  the  tonsillotome.  After  each  operation  the  com- 
ponent parts  should  be  taken  apart,  washed  and  dried;  otherwise 
it  will  rust  and  be  unfit  for  use  when  next  required.  And  should 
the  edge  be  dulled,  it  must  be  sharpened. 

As  a  training  in  the  operation  of  tonsillotomy  with  the  ton- 
sillotome, the  inexperienced  would  do  well  to  learn  the  move- 
ments of  the  instrument  in  the  section  of  some  soft  material;  nor 
in  this  training  practice,  must  the  novice  introduce  his  own  finger, 
as  the  writer  once  knew  a  physician  to  do,  with  the  result  of 
cutting  himself. 

The  operation  consists  essentially  of  three  jorincipal  acts: 
First,  having  the  patient's  mouth  securely  opened^  pass  in  the 
instrument  and  carefully  include  the  tonsils,  all  neighboring 
structures  being  excluded;  then  thrust  the  adjusted  transfixor 
through,  and  slightly  uplift  the  included  part;  now,  firmly  hold- 
ing the  outer  blade  with  one  or  more  fingers,  withdraw  the  inner 
or  cutting  blade;  this  last  act  severs  the  included  tonsils,  when 
the  instrument  with  the  excised  part  is  withdrawn. 

Of  the  three  methods  of  removing  the  tonsils,  viz.,  with  the 
bistoury,  scissors  or  tonsillotome,  general  authority  and  usage 
sanction  the  last  instrument,  as  the  one  with  which  the  excision 


708  TONSIL. 

can  be  done  most  rapidly,  easily  and  safely;  if  an  exception  be 
made,  it  is  the  use  of  the  scissors  in  excising  the  tonsils  in  the 
adult. 

The  question  is  often  asked  by  the  patient  whether  the  removal 
of  the  hypertrophied  part  will  give  future  exemption  from  a 
regrowth  of  tonsillar  structure;  as  answer,  such  exemption  can 
be  promised  in  those  cases  in  whicli  the  greater  portion  of  the 
tonsil  has  been  removed  ;  such  a  patient  need  not  fear  recurrence: 
but  if,  as  often  occurs,  the  removal  has  been  but  midway  to  the 
base,  then  the  stump  may  regrow;  yet  such  recurrent  develop- 
ment rarely  reaches  such  volume  as  to  require  another  operation. 

Another  query  often  made  is  whether  the  excision  will  guard 
against  tonsillitis  in  a  patient  who  has  been  the  subject  of  it;  to 
this  a  reserved  answer  should  be  given ;  for  the  writer  has  observed 
several  cases  in  which  suppurated  tonsillitis  appeared,  even 
though  the  tonsil  had  been  removed.  The  explanation  of  this 
is  that  in  the  work  a  part  of  the  tonsil  had  not  been  removed ; 
follicular  structure  adjacent  to,  or  concealed  under,  the  pharyn- 
geal arches,  had  escaped  excision.  In  a  few  cases  of  the  kind,  in 
the  interim  between  attacks,  the  writer  has  re-operated,  doing 
the  work  with  tenaculum  and  scissors,  or  with  a  sharp-edged 
curette,  similar  to  that  used  by  the  gynecologist.  The  curette  can 
excavate  the  tonsillar  structure  to  a  sufficient  depth  beneath  the 
arches,  wlien  the  latter  encroach  on  the  tonsil. 

The  work  of  tonsillotomy  is  not  free  from  accident  and  unex- 
pected contingency. 

The  most  unfortunate  accident  that  can  occur  is  the  wounding 
of  tlie  internal  carotid  artery.  Be'clard,  Burns  and  other  surgical 
writers  have  witnessed  or  known  of  this  accident.  The  writer 
has  been  told  by  an  eye-witness  that  in  a  tonsillotomy  done  by 
Dr.  Geddings,  a  surgeon  of  South  Carolina,  the  carotid  was  opened 
and  the  life  of  the  child  was  only  saved  by  quickly  tying  the 
primitive  carotid  artery.  The  ascending  palatal  artery  may  be 
abnormally  large,  and  if  wounded,  a  violent  bleeding  would 
occur. 

An  unfortunate  contingency,  yet  luckily  a  rare  one,  is  frac- 
ture of  the  cutting  blade  of  the  tonsillotome.  The  })eril  from 
such  accidentis  that  the  sharp  fragment  may  fall  into  the  larynx  or 
(Bsopliagus,  and  in  either  case  do  great,  and  possibly  fatal,  injury. 
In  such  a  case  every  prudent  effort  should  be  made  to  remove 
the  foreign  body. 

In  case  the   internal  carotid  be   opened,  the  wound  should 


TONSILLOTOMY.  709 

instantly  be  compressed  with  the  finder,  either  directly  applied 
or  indirectly  on  a  piece  of  sponge  or  lint;  and  while  the  bleeding 
is  thus  controlled  by  an  assistant,  the  common  carotid  should  be 
rapidly  sought  for  and  tied  in  its  upper  part.  And  if  haemor- 
rhage still  continues  from  the  distal  end,  as  commonly  occurs, 
then  the  compression  on  the  wound  should  be  continued  digitally 
or  instrumentally. 

In  every  case  of  tonsillotomy,  the  wound  should  be  kept  under 
observation  until  the  bleeding  has  ceased,  which  commonly 
occurs  after  a  few  minutes.  In  the  child,  the  blood  may  con- 
tinue to  escape  unobserved,  since  it  is  swallowed ;  and  in  this 
way  fatal  lia^morrhage  has  occurred:  the  true  condition  being 
unsuspected  until  it  was  too  late.  An  instance  of  this  kind  fell 
within  the  writer's  notice.  A  surgeon  of  reputation  excised  the 
tonsils  of  a  child  one  afternoon;  the  followiug  morning  the 
writer  was  hastily  summoned  and  found  the  child  dying;  and 
with  the  history  that  its  tonsils  had  been  removed  the  day 
before,  and  that  a  short  time  before  my  arrival  it  had  vomited  a 
large  quantity  of  blood;  and  until  this  vomiting,  the  parents  had 
not  suspected  bleeding.     The  child  died  soon  after  my  arrival. 

The  bleeding  may  cease,  and  afterwards  start  again;  an 
instance  of  this  occurred  in  the  writer's  practice.  An  enlarged 
tonsil  in  an  adult  was  removed;  some  hours  afterwards,  the 
Avriter  was  summoned,  and  found  that  bleeding  had  commenced 
some  six  hours  after  the  operation.  On  examining  the  throat,  a 
small  stream  of  blood  was  purling  from  tl^e  wound.  This  bleed- 
ing was  easily  controlled  by  the  pressure  of  a  finger  against  the 
wound;  the  pressure  was  made  by  tlie  writer  for  some  minutes, 
when  the  man  offering  to  do  the  work,  the  task  was  committed 
to  him  with  satisfactory"  result.  A  good  recovery  was  obtained, 
though  a  large  amount  of  blood  was  lost  before  assistance  was 
sought. 

Since  fingers  tire,  or  may  be  bitten  by  the  patient,  a  better 
substitute  for  them  is  a  forceps-like  instrument,  which  once 
placed  in  position,  will  maintain  constant  pressure;  but  while 
such  instrument  is  being  gotten,  digital  compression  may  be 
done  directly,  or  through  the  medium  of  lint  or  sponge  laid  on 
the  bleeding  surface.  This  immediate  compression  may  be 
aided  by  indirect  pressure  on  the  common  carotid,  as  advised  by 
Gensoul,  to  control  such  bleeding.  As  instrument  for  the  com- 
pression, long-bladed  forceps  may  be  employed;  of  these,  one 
blade  is  passed  into  the  mouth  and  placed  directly  on  tlie  bleed- 


710  TONSIL. 

ing  surface,  or  a  piece  of  sponge  may  intervene;  the  other  blade 
may  rest  on  the  angle  of  the  jaw.  A  pair  of  forceps  specially 
constructed  for  this  work  has  been  devised  by  Ilatin.  In  the 
absence  of  a  special  instrument,  any  pair  of  long-bladed  forceps 
would  answer  the  purpose.  And  if  this  is  not  present,  one  might 
extemporize  a  compressor  from  a  strip  of  lead  or  copper,  which 
being  bent  into  a  U-forra,  one  of  its  ends  is  to  be  placed  on  the 
tonsil,  and  the  other  outside,  and  then  the  ends  can  be  forced 
towards  each  other,  and  remaining  so,  continuous  compression 
would  be  made  on  the  wounded  surface.  Such  compression 
should  be  continued  for  two  or  three  days;  and  the  appliance 
should  be  removed  in  the  morning,  so  that,  for  some  hours,  the 
wound  could  be  carefully  watched. 

Where  the  bleeding  was  not  great,  Chassaignac  controlled  it 
with  a  piece  of  ice,  which  he  pressed  for  some  time  against  the 
bleeding  surface.  As  local  means  in  such  cases,  the  writer 
would  recommend  tannin  in  powder,  or  the  touching  of  the  part 
with  the  tincture  of  galls  or  catechu;  from  his  experience,  the 
writer  greatly  j)refers  the  vegetable  astringents  to  the  salts  of 
iron,  which  are  so  often  employed  to  control  bleeding.  The  fer- 
ruginous astringents  have  some  disagreeable  accompaniments 
when  used  in  the  mouth  to  cheek  bleeding.  They  darken  the 
teeth,  and  injure  their  enamel;  and  they  blacken  the  tongue  and 
buccal  mucous  membrane.  They  overdo  the  intended  purpose; 
for  besides  forming  the  haemostatic  clot,  they  have  a  superficial 
escharotic  action  on  the  excised  surface;  so  that  when  the  eschar 
falls  there  may  be  bleeding  from  the  raw  surface.  To  control 
slight  but  troublesome  bleeding,  the  thermal  cautery  has  been 
successfully  used;  the  objection  just  mentioned  against  the  salts 
of  iron,  obtains  against  the  actual  cautery;  the  work  is  liable  to 
be  overdone,  and  the  detaching  eschar  leaves  a  surface  which 
can  easily  bleed. 

But  in  cases  in  which  the  bleeding  is  very  profuse,  it  would 
be  unwise  to  lose  time  in  the  use  of  the  means  mentioned,  but 
the  surgeon  should  proceed  immediately  to  ligation  of  the  prim- 
itive carotid  artery;  in  such  prompt  action,  there  is  much  greater 
security  than  in  delay;  for  if  the  latter  course  be  pursued,  so 
much  blood  may  be  lost  that  the  patient  may  die  from  this 
cause,  even  though  the  ligation  be  done. 

Tonsillar  Tumors. — Apart  from  enlargement  through  simple 
hypertrophy,  the  tonsil  is  seldom  the  site  of  neoplastic  develop- 
ment; still  malignant  disease  of  the  type  of  sarcoma  and  car- 


TONSILLAR     TUMORS.  711 

cinoma,  or  the  latter's  equivalent  epithelioma,  has  made  its  pri- 
mary appearance  in  the  tonsil.  The  writer  has  seen  a  case  of 
tonsillar  sarcoma.  Epithelioma  developing  in  the  walls  of  the 
pharynx,  and  still  oftener  in  the  hase  of  the  tongue,  may  attack 
the  tonsil  by  migration.  The  author  has  seen  several  examples 
of  this  kind.  Malignant  disease  here  has  its  usual  history  of 
gradually  implicating  circumjacent  and  subjacent  parts,  with 
final  ulcerative  destruction  of  the  structures:  life  endino;,  after 
montlis  of  torture,  through  ichorous  pneumonia,  or  starvation. 

Treatment. — In  1856,  Langenbeck  published  the  treatment  of 
tonsillar  cancer  by  tliermal  cauterization.  Though  the  disease 
was  not  cured,  yet  in  two  cases  thus  treated,  the  disease  was 
retarded,  and  life  was  j^rolonged  for  some  months. 

For  a  time,  chief  attention  in  treatment  was  directed  to  means 
which  retarded  the  progress  of  the  disease;  but  the  unsatisfactory 
results  thus  obtained  finally  led  to  more  radical  measures,  in 
which  it  was  attempted  to  excise  the  affected  tonsil.  Operative 
work  in  this  line  has  been  done  by  Cheever,  Mickulicz,  Lange 
and  others. 

In  1883,  Mickulicz  rejoorted  the  removal  of  tonsillar  cancer, 
through  an  external  opening,  made  as  follows:  An  incision  is 
made  from  the  mastoid  process  to  the  os  hyoides;  the  soft  parts 
are  then  detached  from  the  angle  of  the  jaw,  internally  and 
externally,  and  the  angle  then  exsected;  through  the  opening 
thus  made,  an  entrance  is  prepared  into  the  pharynx,  and  the 
tonsil  is  reached  and  removed.  Thus  done,  the  vessels  become 
visible  and  can  be  pulled  out  of  the  way;  or  if  wounded,  they 
can  be  tied.  The  mutilation  of  the  maxilla  inferior  is  a  serious 
objection  to  the  method  of  Mickulicz;  and  to  avoid  this,  Cheever 
and  Lange  have  made  an  opening  at  the  angle  of  the  jaw  into 
the  pharynx;  and  through  such  opening  they  reached  and 
excised  malignant  disease  in  the  base  of  the  tongue,  or  in  the 
tonsil. 

In  pioneering  such  a  route  to  the  pharynx,  the  position  of  the 
external  carotid  artery  must  be  remembered ;  this  lies  under  the 
parotidean  sulcus,  or  depression  between  the  mastoid  process  and 
mandibular  angle,  in  which  lies  the  dependent  portion  of  the 
parotid  gland.  The  lower  branches  of  the  cervico-facial  portion 
of  the  facial  nerve  lie  in  the  same  dejDression,  and  they  are  neces- 
sarily injured  or  severed,  in  an  incision  here;  hence  the  risorius 
Santorini  muscle  is  thus  temporarily,  or  permanently,  2:)alsied. 
The   cutaneous   incision  should    lie  just  behind  the  lower  jaw, 


712  TONSIL. 

commencing  an  inch  above  the  angle,  and  extend  an  inch  and 
a  half  along  the  lower  border  of  the  bone.  In  the  horizontal 
portion  of  the  cut,  the  facial  artery  will  be  met,  and  it  must  be 
ligated.  From  the  middle  of  this  semilunar  cut,  a  vertical  incis- 
ion must  be  carried  an  inch  and  a  half  downwards.  Through 
such  a  cut  between  the  lower  jaw  and  the  digastric  muscle,  a 
free  way  is  opened  into  the  throat;  and  in  its  construction,  the 
external  and  internal  carotid  being  exposed  early  in  the  work, 
they  can  be  avoided;  and  if  the  external  jugular  or  its  formative 
branches,  and  the  facial  artery  be  doubly  tied  and  divided, 
the  operation  becomes  nearly  a  bloodless  one.  This  cervico- 
pharyngeal  opening  can  be  utilized  for  extirpation  of  malignant 
disease  in  the  pharynx,  tonsil  and  base  of  the  tongue;  and  in  the 
last  case,  the  cut  permits  of  ligation  of  the  lingual  artery  in  the 
first  portion  of  its  course,  whereby  one-half  of  the  tongue  will  be 
rendered  nearly  bloodless. 

This  cervico-pharyngeal  route,  besides  the  facility  which  it 
offers  for  the  removal  of  malignant  disease  within  the  throat,  has 
the  additional  advantage  that  it  o])ens  to  view  the  lymphatic 
glands  which  sooner  or  later  become  implicated,  when  there  is 
malignant  disease  within  the  throat;  and  such  infected  glands 
require  removal,  and  if  this  is  not  done,  there  will  be  speedy 
recurrence  of  the  disease.  The  field,  when  well  opened,  must  be 
diligently  explored,  and  every  gland  which  is  found,  whether 
large  or  small,  should  be  removed.  A  favorite  lurking  place  for 
such  infection,  as  tlie  author  has  verified,  is  in  glands  which  lie 
on  or  near  the  bifurcation  of  the  primitive  carotid.  The  wound 
made  also  offers  the  best  opportunities  for  thorough  drainage  of 
the  excreta  which  are  thrown  off  from  the  wounded  parts;  and 
thus  pulmonary  disease  through  swallowed  ichor  is  avoided,  and 
speedy  healing  of  the  wound  is  obtained;  four  weeks, at  most, 
suffice  for  recovery.  The  scar  remaining  in  the  male  is  covered 
by  his  beard ;  and  even  in  the  beardless  it  is  not  very  conspicuous. 

As  a  more  expeditious  plan  than  the  one  just  described,  and 
one  by  which  the  loss  of  blood  would  be  reduced  to  a  minimum,  the 
writer  would  suggest  to  begin  the  woric  by  ligating  the  external 
carotid  artery;  and  then  through  the  cut  made,  continue  the 
incision  into  the  pharynx.  This  prophylactic  ligation  would 
enable  the  work  to  be  done  in  almost  bloodless  structure,  as  the 
writer  has  verified. 


CHAPTER  XXI. 


PHARYXX. 


The  pharynx  is  the  site  of  inflammation,  which  may  primarily 
arise  in  it,  or  the  affection  may  appear  secondarily  from  inflamma- 
tion, which,  beginning  in  the  tonsils,  extends  thence  to  adjacent 
parts;  and  in  either  case,  the  symptoms  are  cognate  to  tonsillitis, 
and,  like  it,  tend  to  suppuration.  The  best  treatment,  if  the 
patient  be  seen  early,  is  to  scarify  the  affected  parts,  and  thus  let 
the  blood  which  has  accumulated  in  the  surface  be  evacuated. 
If  the  patient  be  an  adult,  in  whom  such  treatment  can  be  prac- 
ticed with  more  facility  than  in  the  child,  free  scarification 
once  suffices  to  arrest  the  inflammation;  afterwards,  resolution 
will  be  promoted  by  painting  the  surface  daily  with  the  following: 

]^.    Tr.  lodini  compos. 

Tr.  Gallse aa  gss 

Misce. 

similar  to  what  was  advised  for  the  inflamed  tonsil. 

Abscess  of  the  Pharynx. — Pharyngeal  abscess  was  first  carefully 
observed  and  written  upon  by  Abercrombie,  in  1819;  a  few  years 
later,  the  disease  was  studied  by  Fleming,  Gillette,  Jacquemart 
and  others.  Such  abscess  may  appear  as  an  acute,  or  as  a  chronic 
process.  It  is  often  named  according  to  its  sites;  thus  we  have 
abscess  named  retro-pharyugeal,  latero-pharyngeal,  and  antero- 
pharyngeal,  according  as  it  is  located  behind,  at  the  side  or  in  the 
front  portion  of  the  pharynx.  The  most  usual  species  is  the 
retro-ph  ary  ngeal . 

Acute  pharyngeal  abscess  occurs  most  commonl}^  in  the  infant; 
thus  of  forty-six  cases  observed  by  Gautier,  thirty-five  were  seen 
in  young  children;  and  in  twenty-six,  the  infant  was  less  than 
one  year  old.  Abelin  saw  the  affection  in  infants  only  three 
months  old. 

Gillette,  of  Paris,  in  1868,  wrote  on  the  retro-pharyngeal  abscess, 
drawing  his  material  chiefly  from  the  observations  of  such 
46  (713) 


714  I'lIAKYNX. 

abscess  by  French  surgeons.  In  retro- pliaryngeal  abscess,  \vhieh 
is  the  common  form,  he  claims  that  the  point  of  origin  and  of 
commencement  is  in  two  lympliatic  glands,  peculiar  to  infancy, 
and  which  are  situated,  according  to  the  researches  of  Gautier, 
Cocteau  and  others,  on  a  level  with  the  second  vertebra,  between 
the  superior  constrictor  pharyngeal  muscle  and  tlie  anterior  recti 
muscle  of  tiie  upi>er  part  of  the  s[»ine;  these  glands  are  usually 
two  in  number,  separated  by  an  interval  of  a  half  inch,  and  they 
lie  in  a  loose  connective  tissue.  They  are  nearly  a  half  inch 
long  and  about  a  quarter  of  an  inch  broad;  in  the  opinion  of 
some  ol)servers  these  dimensions  iiiay  be  due  to  abnormal  devel- 
opment, and  in  normal  state,  the  glands  are  believed  to  be  much 
smaller.  In  later  childhood  these  glands  atrophy  and  vanish. 
Gillette  saw  but  one  in  a  child  wliich  had  passed  beyond  infancy. 
The  retro-pharyngeal  abscess,  which  occurs  so  much  oftener  in 
children,  is  thought  by  Gillette  and  Verneuil  to  begin  in  this 
infantile  gland.  The  cases  seen  have  been  of  different  dimensions ; 
it  may  be  limited  to  a  small  space,  or  it  may  reach  down  to  the 
sixth  or  seventh  vertebra. 

Predisposing  causes  of  the  disease  are  rachitis,  scrofula,  tuber- 
culosis, syphilis  and  feebleness  of  body.  It  is  frequently  preceded 
by  disease  in  the  throat,  tongue  and  tonsils;  and  commencing  in 
these  sites,  it  is  probable  that  it  is  thence  propagated  by  structural 
continuity.  As  local  irritant,  a  foreign  body  lodged  in  the  throat, 
has  caused  abscess;  thus  a  coin  has  acted. 

There  are  two  stages:  the  inflammatory  and  the  suppurative; 
and  in  the  former,  there  is  diSiculty  in  swallowing,  return  of  the 
material  swallowed,  whether  this  be  liquid  or  solid;  dryness  of 
the  throat  and  a  teasing  cough.  If  the  subject  be  an  infant  at 
the  breast,  it  has  difficulty  in  drawing  the  milk.  Later,  there  is 
salivation,  chills,  oedema  and  swelling  of  the  cervical  glands. 
The  voice  becomes  hoarse  or  suppressed,  and  the  head  is  bent  to 
one  side,  or  backwards.  There  is  often  difficulty  of  opening  the 
mouth,  in  consequence  of  contraction  of  the  muscles  of  mastica- 
tion; viz.,  a  trismus  which  might  mislead  by  awakening  the 
suspicion  of  tetanus.  If  the  jaws  be  opened,  the  exploring  finger 
will  find  swelling  in  the  throat. 

Through  narrowing  of  the  faucial  isthmus,  not  only  swelling 
but  also  breathing  is  obstructed.  Hearing  may  be  impaired,  or 
temporarily  lost,  through  closure  of  the  Eustachian  tube.  Some- 
times vision  may  be  interfered  with.  The  pus,  when  formed  in 
considerable  quantity,  may  press  on  the  vagus  and  the  sympa- 


ABSCESS    OF    THE    PHARYNX.  715 

thetic  nerve;  and  thence  fundamental  trouble  can  arise  in  the 
peripheral  districts  which  receive  innervation  from  these  nerves; 
this  fact  analyzed  offers  an  explanation  of  the  lingual,  pharyngeal, 
laryngeal,  pulmonic  and  gastric  troubles,  which  singly  or  in 
union  are  present.  The  closeness  of  the  internal  carotid  and 
internal  jugular  vein  to  the  abscess  may  disturb  the  normal  influx 
and  efflux  of  the  blood  of  the  brain;  and  in  the  worst  cases,  the 
internal  jugular  may  become  the  site  of  thrombus,  which  may 
reach  up  into  the  sinuses  of  tlie  dura  mater,  and  induce  a  fatal 
termination. 

Pharyngeal  abscess  is  generally  preceded  by  some  auginous 
affection  or  traumatic  cause;  and  this  in  the  child  may  be,  for  a 
time,  overlooked.  The  first  indication  that  pus  is  present,  is  the 
difficulty  which  the  patient  has  in  swallowing ;  and  this  evidence 
will  further  be  enforced,  if  swelling  be  found  in  the  throat.  As 
the  jaws  are  usually  tightly  closed,  it  is  difficult  to  obtain  a  view 
of  the  affected  parts ;  and  to  do  this,  the  handle  of  a  large  spoon, 
or,  better  still,  a  spatula,  should  be  passed  between  the  teeth, 
backwards,  to  the  fauces.  The  introduction  of  such  an  instru- 
ment will  excite  an  effort  to  vomit,  by  which  the  mouth  is'well 
opened;  and  during  tliis,  a  wedge-shaped  cork  must  be  thrust 
between  the  molar  teeth,  so  as  to  maintain  the  jaws  well  asunder. 
Through  the  opening  thus  prepared,  the  finger  can  safely  enter 
and  reach  the  affected  part ;  then  palpation  will  detect  fluctua- 
tion, or  pointing  of  pus,  if  an  abscess  exists;  as  Gosselin  says,  the 
displaced  pus  recoils  as  soon  as  the  finger  is  lifted.  If  the  abscess 
has  lateral  position,  the  fluctuation  is  less  sensible  to  the  finger, 
and  the  touch  will  be  aided,  if  counter-pressure  is  made  with  the 
other  hand,  on  the  outside.  And  if  the  pus  lies  still  more  ante- 
riorly, it  may  be  detected  by  bi-manual  pressure  on  the  sides  of 
the  throat. 

From  the  divergent  observations  of  different  writers  it  is  diffi- 
cult to  give  the  duration  of  the  disease  ;  among  seven  cases,  the 
disease  lasted  from  one  to  ten  days;  in  twelve  others,  the  course 
was  from  ten  to  twenty  days;  and  in  fourteen  others,  the  dura- 
tion varied  from  twenty  to  sixty  days.  However  divergent  and 
discordant  these  numbers  may  be,  they  do  not  deter  the  statistician 
from  deducing  his  wonted  percentage  from  them;  a  result  of  no 
use  to  the  practitioner;  to  the  latter,  the  important  truth  is  that' 
the  pharyngeal  abscess,  through  tumefaction,  closes  the  fauces, 
through  asphyxia,  and  finally,  if  unrelieved,  destroys  the  patient. 

The  prognosis  is  more  auspicious  according   as  the  disease 


•IG 


PHARYNX. 


has  been  correctly  diagnosed  at  an  early  period ;  thus  Gautier, 
who  collected  twenty-five  cases  in  wliich  the  disease  had  not  been 
recognized,  reports  that  all  died;  but  in  a  list  of  sixty-six  cases 
which  liad  been  early  diagnosed,  there  were  but  sixteen  deaths. 
Again  Roustan  found  that  in  a  series  of  eleven  cases  wrongly 
<liagnosed,  there  were  eleven  deaths;  but  in  twenty-seven  cases 
which  were  correctly  diagnosed,  there  were  ten  deaths.  The 
reader,  along  wMth  the  author,  will  doubtless  admire  the  candor 
that  adorns  these  statements,  and  will,  perhaps,  wonder  whetlier 
the  admission  of  so  many  mistakes  would  have  been  made  else- 
where. A  writer  who  publishes  his  errors  should  be  assigned  a 
front  place  among  those  who  are  enlarging  the  domain  of  medi- 
cine; and  the  gaudy  laurel  which  Fame  hastens  to  place  on  the 
brow  of  him  whose  daring  has  ended  luckily,  would  be  more 
fittingly  bestowed  on  him  who  has  announced  a  faihire. 

There  is  a  chronic  form  of  phar3nigeal  abscess,  in  which  the 
course  and  evolution  are  latent;  and  which,  quite  unheralded  by 
any  of  the  S3'mptoms  wliich  attend  the  acute  form,  finally 
announces  itself  by  difficulty  of  swallowing.  Inspection  then  of 
the  fauces  reveals  a  collection  of  pus  in  the  lateral  or  posterior 
wall  of  the  pharynx.  The  patient,  in  such  a  case,  is  of  tubercu- 
lous, scrofulous,  or,  more  rarely,  syphilitic  habit.  And  along 
with  the  abscess,  not  unfrequeutly  there  may  be  vertebral  caries 
seated  in  the  body  of  one  or  more  of  the  cervical  vertebrae.  And 
then,  mingled  with  the  pus  there  may  be  osseous  detritus;  or 
even  a  necrosed  fragment  of  bone  of  some  size  may  be  found  in 
the  abscess. 

Of  whatever  nature  the  general  dyscrasy  may  be,  the  adja- 
cent cervical  glands  will  be  im})licated;  and  this  tumefaction 
may  lead  to  an  exploration  of  the  throat,  and  discovery  of  the 
pharyngeal  affection,  long  before  the  advent  of  dysphagia. 

Treatment. — The  proper  treatment  of  the  pharyngeal  abscess 
is  to  evacuate  the  pus  at  once  ;  for  if  this  be  delayed,  the  purulent 
material  will  descend  to  a  location  from  which  the  evacuation 
will  be  much  more  difficult.  Instances  have  been  ol)served  in . 
which  the  pus  has  descended  into  the  posterior  mediastinum, 
causing  irreparable  injury. 

There  are  two  routes  through  which  the  pus  may  be  given 
exit:  one  through  the  mouth,  and  another  in  which  the  material 
is  given  outlet  through  an  opening  made  in  the  upper  side  of 
the  neck. 

The  usual  method   has  been  to  open  and  evacuate  the  pus 


ABSCESS    OF    THE    PHARYNX.  717 

directly  into  the  fauces;  and  as  far  as  possible,  to  allow  the  pus 
to  escape  through  the  mouth.  Tliis  plan  has  certain  trouble- 
some accompaniments,  to  wit,  that  the  material  tends  to  escape 
downwards,  rather  than  upwards  and  forwards;  and  then  the 
material  either  enters  the  stomach  and  is  absorbed,  or  it  passes 
into  the  lungs,  and  awakens  morbid  action  there.  Again,  the 
opening  in  the  pharynx  permits  the  lodgment  of  particles  of 
nutriment,  or  other  materials  which  may  be  swallowed.  Not- 
withstanding these  embarrassing  conditions,  the  writer  would 
open  the  abscess,  on  the  inside  of  the  throat,  in  every  case  of 
pharyngeal  abscess  of  acute  character.  The  opening  may  be 
made  with  a  scalpel  of  long  handle;  meantime,  the  patient's  head 
should  be  so  situated  that  the  liberated  matter  will  have  ready 
escape  through  the  mouth.  If  the  subject  be  a  child,  the  jaws 
should  be  held  asunder  by  some  body  interposed  between  the 
molar  teeth.  It  is  probable  that  the  aperture  made  v/ill  close 
and  require  re-opening;  this  can  be  done  with  a  probe  or  blunt 
dissector.       • 

In  the  event  of  the  abscess  being  of  chronic  development,  and 
it  being  probable  that  the  cervical  vertebrae  are  involved,  then  it 
has  been  recommended  to  liberate  the  pus  by  means  of  an  incis- 
ion made  on  the  side  of  the  neck,  so  directed  as  to  reach  the 
purulent  cavity.  Such  an  operation  was  proposed  and  done  by 
Chiene,  of  Edinburgh,  a  few  years  ago.  And  as  a  preliminary 
step  in  the  work,  he  performs  tracheotomy.  Inasmuch  as  this 
would  be  no  small  quota  of  the  assault  made  on  the  patient,  the 
writer  would  not  resort  to  it  unless  asphyxia  were  impending 
from  occlusion  of  the  pharynx;  but  if  suffocation  were  immi- 
nent, tracheotomy  should  be  performed  as  a  prophylactic  act. 
And  if  this  be  performed,  then  ansesthetic  inhalation  must  be 
done  through  the  tracheal  canula.  The  incision  is  now  to  be 
made,  commencing  with  an  external  cut,  not  less  than  two  inches 
and  a  half  long,  along  the  posterior  border  of  the  sterno-cleido- 
mastoid  muscle;  and  in  this  the  ascending  branches  of  the  super- 
ficial cervical  plexus  should  be  avoided:  easily  done  by  carrying 
the  knife  behind  them.  Next,  there  will  probably  be  met,  espe- 
cially in  the  dyscrasic  subject,  enlarged  lymphatic  glands,  which 
should  be  removed.  The  advancing  incision  should  be  directed 
obliquely  inwards  and  backwards;  and  thus  the  transverse  pro- 
cesses of  the  second  and  third  cervical  vertebrae  will  be  reached, 
in  front  of  which  the  incision  must  pass.  The  sterno-cleido- 
mastoid  is  to  be  drawn  forwards  with  a  retractor,  and  the  separa- 


718  PHARYNX. 

tioii  of  tlie  parts  to  be  carefully  continued  until  the  pus  is  reached ; 
and  in  this  work,  to  avoid  oj^ening  into  the  fauces,  the  jaAvs  hav- 
ing been  separated,  a  finger  of  one  hand  introduced  into  the 
pharynx  will  serve  as  a  controlling  guide  to  the  work  wliich  the 
other  hand  is  doing.  The  deeper  portion  of  the  dissection  should 
be  done  with  a  blunt  dissector.  This  opening  must  be  near  the 
transverse  processes  and  the  bodies  of  the  cervical  vertebrae;  for 
thus  placed  it  will  be  situated  quite  behind  the  vessels  and  nerves 
which  lie  in  the  lateral  wall  of  tlie  pharynx.  AVhen  the  pus 
cavity  is  reached,  a  free  opening  should  be  made,  and  the  content 
washed  out  with  an  alkaline  solution;  and  this  may  consist  of  a 
twenty  per  cent  solution  of  carbonate  of  potash;  such  solution 
is  approximately  formed  by  adding  three  drachms  of.  the  salt  to 
two  ounces  of  water.  The  solvent  quality  of  the  alkaline  solution 
will  aid  in  cleansing  out  the  cavity;  and  afterwards  the  rinsing 
out  may  be  finished  with  an  alcoholic  or  sublimated  solution. 
The  opening  is  to  be  kept  patent  by  a  drainage  tube  as  long  as 
pus  is  formed,  and  detersive  irrigation  continued  uniil  the  escap- 
ing material  is  of  serous  character.  If  the  bony  wall  be  impli- 
cated, then  the  affected  surface  should  be  scraped  off  with  a  strong 
curette;  and  in  this  case  the  outlet  to  the  site  of  disease  must  be 
maintained  open  for  a  much  longer  time;  but  if  there  be  no 
osseous  disease,  the  wound  may  be  allowed  to  close  in  a  few  days, 
as  was  done  in  a  successful  operation  of  this  kind  reported  by 
Carless,  of  King's  College  hospital. 

Should  the  pus  have  lateral  rather  than  median  situation, 
then  the  incision  should  be  made  on  the  side  corresponding  to 
the  abscess;  and  then  the  recovery  would  be  more  rapid,  since  in 
such  a  case  the  vertebrse  would  probably  not  be  affected,  and  the 
opening  to  the  abscess  would  be  less  deep. 

The  necessity  of  preliminary  tracheotomy  has  been  favored 
and  opposed  by  those  who  have  written  on  the  pharyngeal 
abscess.  The  advantages  claimed  for  it  are  that  it  at  once  dis- 
poses of  the  peril  of  asphyxia;  and,  especially,  it  guards  against 
the  penetration  of  pus  into  the  air-passages,  if  the  abscess  is 
opened  intentionally  or  accidentally  on  the  inside.  For,  however 
carefully  the  opening  be  made  into  tlie  fauces,  some  purulent 
material  must  be  inhaled  into  the  lungs.  Even  if  the  intra- 
pharyngeal  opening  is  made  with  the  head  dependent,  as  pro- 
posed and  practiced  by  Rose  in  operations  on  the  nose  and  throat, 
then  the  strong  inspiratory  effort,  which  is  involuntarily  made, 
will  carry  purulent  materials  into  the  lungs.     And  even  trache- 


ULCERATION    OF    THE    PHARYNX.  719 

otoiii}'  cannot  prevent  tliis  unless  the  pharynx  below  be  plugged, 
which  should  be  done  with  sponges.  The  same  may  be  accom- 
plished b}^  tamponing  the  trachea  above  the  opening  made  in  it, 
which  can  also  be  done  with  sponges. 

Notwithstanding  the  facts  which  have  been  offered  as  a  plea 
in  behalf  of  preliminary  tracheotomy  in  pharyngeal  abscess,  the 
writer  thinks  there  are  but  few  cases  in  which  it  would  be 
necessary. 

Jjlceration  of  the  Pharynx. — Ulceration  of  the  pharynx  may 
arise  from  an  acute  inflammatory  process,  whence  arises  an  ulcer- 
ative breach  of  surface;  or  the  ulcer  may  arise  from  some  consti- 
tutional disease,  which  may  be  of  syphilitic  or  tubercular  nature. 

Ulceration  occurring  as  an  event  of  some  acute  inflammatory 
process,  is  usually  of  brief  duration,  vanishing  soon  after  the 
causal  aff'ection  has  disappeared.  For  such  ulcer  simple  remedies 
only  are  required;  the  following  gargle  may  be  used: 

B^.    Potass.  Chlorat 9ii 

Aqiise  Menthse 5  viij 

Misce. 
Use  three  times  a  day.     For  the  same  purpose  claret  wine  diluted 
with  an  equal  part  of  water  may  be  used. 

The  chronic  form  of  ulcer,  which  is  but  a  local  manifestation, 
and  a  fractional  one  at  that,  of  a  constitutional  disease,  is  a  most 
troublesome  affection  which  may  indirectly  imperil  life.  The 
better  knowledge  now  existing  of  syphilis  and  of  the  means  to 
cure  it  rarely  permits  the  development  of  severe  pharyngeal 
ulceration ;  exceptionally,  however,  such  secondary  manifestation 
is  seen.  In  such  cases,  the  affection  of  the  pharynx  renders 
deglutition  painful,  so  that  the  patient  takes  but  an  insufficient 
amount  of  food ;  whence  follow  debility,  emaciation  and  a  rapid 
waning  of  the  forces  of  life. 

Such  dyscrasic  ulceration  is  preceded  by  a  period  of  infiltra- 
tion; in  the  syphilitic  subject  this  is  gummatous  in  character 
while  it  is  tubercular  in  the  scrofulous  patient;  and  later,  the 
neoplastic  infiltrate  disintegrates,  and,  breaking  down,  there 
remains  a  corresponding  breach  or  ulcer.  And  if  there  exist 
isolated  points  of  infiltration,  corresponding  points  of  solution 
will  appear,  of  which  the  widening  areas  enlarge  until  there  is 
formed  by  their  common  fusion,  a  large  denuded  surface.  And 
this  eroding  process,  besides  lateral  and  superficial  extension,  also 
penetrates  into  the  subjacent  structure. 

Besides  the  mode  of  origination  just  mentioned,  the  pharyn- 


720  PHARYNX. 

treal  ulcer  may  result  from  an  abscess,  of  which,  the  inner  wall 
sloughing,  there  may  remain  an  ulcerated  surface  with  but  slight 
tendency  to  heal. 

Pharyngeal  ulcer,  when  occupying  a  large  portion  of  the  wall 
of  the  pharynx,  if  it  heals,  entails  stricture  of  the  pharynx;  and 
this  stenosis,  as  the  author  has  observed,  may  reach  such  a  degree 
of  constriction  as  to  partly  or  totally  obstruct  swallowing. 

Treatment. — Isolated  topical  treatment  of  the  dyscrasic  ulcer 
would  be  of  no  benefit;  such  a  mode  would  resemble  the  pluck- 
ing of  an  occasional  leaf  from  a  tree  while  the  trunk  is  allowed  to 
remain  in  vigorous  growth;  to  cure  the  patient,  the  genetic  dis- 
ease must  be  energetically  treated ;  and  the  preceding  syphilis, 
scrofula  or  other  cachexy  must  take  precedence  in  the  manage- 
ment; and  this  having  received  tlie  prior  and  major  care,  atten- 
tion may  next  be  directed  to  the  local  affection  in  the  throat. 

Tlie  ulcerated  surface  should  be  thoroughly  destroyed  either 
by  curetting  or  the  thermal  cautery;  and,  in  some  cases,  the 
curette  may  be  followed  by  the  cautery.  Thus  the  diseased 
infiltrated  tissue  is  effectually  disposed  of,  and  the  remaining 
structure  is  placed  in  conditions  favorable  for  healing.  If  the 
thermal  cautery  follow  curetting,  the  former  should  be  done 
sparingly.  And  along  with  the  topical  and  constitutional  treat- 
ment, the  nutrition  of  the  patient  demands  special  attention;  he 
should  have  a  rich,  generous  diet,  in  which  there  should  be  a 
due  proportion  of  solid  food.  From  the  writer's  observation, 
meats  in  solid  form  contribute  much  more  to  the  maintenance  of 
the  body,  in  such  cases,  than  liquid  extracts;  in  one  patient, 
though  he  was  bounteously  fed  on  liquid  food,  yet  emaciation 
continued;  finally  the  use  of  meat  in  solid  form  was  followed  by 
immediate  and  rapid  improvement.  Hence  in  such  disease, 
solid  meats  and  eggs  are  invaluable  adjuvants  in  treatment. 

The  cicatricial  contraction  of  the  healing  pharynx  tends  to 
strictural  narrowing,  so  that  after  recovery  normal  swallowing 
is  greatly  obstructed.  To  obviate  this  tendency  to  narrowing, 
dilating  sounds  or  expanding  instruments  should  now  and  then 
be  passed  through  the  pharynx. 

Sometimes  the  case  only  comes  under  observation  after  the 
ulcerated  wall  has  healed,  and  constriction  has  taken  place. 
The  appropriate  treatment  in  such  a  case  is  to  incise  tlie  wall 
vertically,  and  then  dilate  with  sounds;  or,  what  is  better,  one 
may  use  handled  forceps;  and  the  blades  being  passed  below  the 
constriction,    the    handles   are    separated,  and    the    instrument 


PHARYNGEAL    TUMORS.  721 

withdrawn.  In  this  way  the  calibre  can  be  w^idened,  and  by 
persevering  effort,  tliis  can  be  maintained  so ;  yet  to  be  success- 
ful, instrumental  dilatation  must  be  continued  for  a  year  or  two. 

Pharyngeal  Tumors. — The  pharynx  is  the  not  infrequent  site 
of  growths  which  may  arise  there  primarily,  or  extend  to  it  ■ 
through  emigration  from  adjacent  parts.  These  neoplasms  may 
be  benign  or  malignant  in  nature;  the  latter  may  be  sarcoma- 
tous or  carcinomatous  in  species.  The  notorious  naso-pharyngeal 
tumor  may  arise  from  the  upper  part  of  the  posterior  wall;  or 
from  the  roof  of  the  choanse;  and  for  the  description  and  .treat- 
ment of  this  growth,  the  reader  is  referred  to  a  preceding  section 
of  this  work. 

A  benign  tumor  of  polypoid  character  has  been  observed  in 
the  pharynx.  Histologically,  such  tumor  may  be  included  in 
the  group  of  the  fibromata.  It  may  appear  at  any  point  of  the 
pharyngeal  wall;  and,  when  at  the  root  of  the  tongue,  or  the 
base  of  the  epiglottis,  or  wdiere  the  pharyngeal  isthmus  merges 
into  the  larynx  and  ossophagus,  then  the  tumor  may  be  over- 
looked, and  remain  unseen  and  unknown  to  the  patient  until  its 
increased  volume  encroaches  on  the  entrance  of  the  air-passages 
and  interferes  with  respiration;  or  entering  the  oesophagus, 
swallowing  may  be  rendered  difficult,  or  be  entirely  obstructed. 
The  tumor  may  be  so  located,  as  to  obstruct  both  respiration 
and  deglutition.  A  case  of  the  latter  kind  was  reported  to  the 
writer;  the  tumor  had  never  been  recognized  during  life;  but 
the  patient  dying  suddenly  from  suffocation,  an  autopsy  revealed 
a  tumor  situated  near  the  larynx. 

The  determination  and  diagnosis  of  the  intra-pharyngeal 
polyp  may  be  made  by  means  of  the  sound,  digital  palpation  and 
the  pharyngoscopic  mirror;  and  these  are  aided^  by  the  subjec- 
tive symptoms  to  which  the  tumor  gives  origin.  Any  subjective 
sign  should  receive  due  attention,  and  lead  to  a  searching  explo- 
ration of  the  parts. 

When  found,  such  tumor  must  be  radically  removed;  and 
the  facility  or  difficulty  of  doing  this  will  depend  on  whether  the 
growth  is  pedunculated  or  sessile.  If  the  tumor  arise  by  a  nar- 
row footstalk,  its  extraction  is  easily  done;  by  a  pair  of  forceps, 
the  gxowth  can  be  twisted  and  plucked  from  its  ground.  And 
this  may  be  done  through  the  mouth.  But  if  the  location  be 
deep,  and  the  tumor  have  a  broad  sessile  attachment,  the  task  of 
removal  becomes  an  arduous  one;  and  the  work  may  be  done 
through  the  mouth;  or  a  shorter  route  may  be  made  to  it  by  an 


799 


PHARYNX. 


incision  made  between  the  larynx  and  the  carotid  artery. 
Tiirough  an  opening  tlius  formed,  tlie  site  of  origin  could  be 
readied  directly,  and  the  work  of  removal  so  thoroughly  done, 
tliat  a  re-growth  would  be  prevented.  After  closure  of  the  cervi- 
cal wound,  the  nutrition  should  be  maintained  by  means  of 
liquid  food  conveyed  through  an  (esophageal  tube. 

Carcinoma  may  appear  in  the  pharynx,  primarily,  or  as  an 
emigrant;  and  when  occupying  this  site,  modern  surgery  in  tlie 
work  of  removal  has  sought  to  reach  the  growth  by  an  incision 
through  the  side  of  tlie  neck,  or  by  an  opening  in  which  the 
maxilla  inferior  is  divided. 

Through  the  side  of  the  neck,  Langonbeck,  in  1877,  reached 
the  growth  by  the  following  incision:  let  the  knife  start  at  a  point 
midway  ])etween  the  cliin  and  tlie  angle  of  the  jaw,  and  thence 
pass  downwards  over  the  great  cornu  of  the  liyoid  hone  until  it 
reaches  the  level  of  the  cricoid  cartilage;  in  its  course  downwards, 
this  incision  follows  the  direction  of  the  thyro-hyoid  muscle.  As 
the  incision  is  cai-ried  inwards,  the  superior  thyroid,  lingual  and 
facial  arteries  will  be  reached;  the  first  and  second  must  be 
doubly  tied,  and  divided;  and  the  facial  may  also  be  ligated,  if 
it  cannot  be  pulled  upwards  out  of  the  way.  The  digastric  and 
stylo-hyoid  muscles  when  reached  must  be  detached  from  the 
hyoid  bone.  Finally,  the  larynx  is  reached,  and  is  to  l>e  turned 
around  somewhat  on  its  axis  and  pulled  aside,  when  the  phar- 
ynx being  reached,  it  must  be  dissected  from  the  parts  to  which 
it  is  connected.  The  diseased  pharynx  may  be  divided  above, 
on  a  level  with  the  pendulous  veil  of  the  palate;  also  below,  at  a 
point  corresponding  to  the  inferior  limit  of  the  disease.  The 
detachment  is  not  difficult  if  done  at  an  earl}'  period  before  the 
disease  has  reached  into,  or  beyond,  the  tissue  which  separates 
the  pharynx  from  the  parts  external  to  it. 

The  risk  after  the  operation  is  the  penetration  of  pus  and 
other  materials  into  the  lungs,  and  thence  ichorous  (gurgitant) 
pneumonia  can  arise;  to  prevent  or  lessen  these  risks,  Langen- 
beck  tracheotomizes  and  tampons  the  trachea  above,  and  as  fur- 
ther aid  he  sutures  the  epiglottis  to  the  opening  into  the  larynx. 

Fischer  first  opens  between  the  hyoid  bone  and  the  thyroid 
cartilage;  that  is,  he  performs  sub-hyoid  laryngotomy;  and  after 
I'emovirig  the  affected  pharynx,  he  fixes  the  end  of  the  tesophagus 
in  the  wound,  and,  letting  it  heal  there,  the  patient  is  afterwards 
fed  tlirougli  this  opening. 

Klister   and   Kroenlein,  as  fore-act  in  pharyiigotomy,  divide 


FOREIGN    BODIES    IX    THE    PHARYXX.  723 

the  lower  jaw  near  its  angle,  and  then  pass  directly  to  the 
affected  part.  Kroenlein  operated  as  follows :  a  cut  was  made 
from  the  angle  of  the  mouth  to  the  angle  of  the  lower  jaw,  and 
carried  thence  to  the  mastoid  process;  and  then  the  lower  jaw 
was  divided  at  the  angle,  and  the  ascending  portion  was  so  pulled 
aside  that  the  pharynx  can  be  entered.  After  removal  of  the 
disease,  the  ramus  is  restored  to  place,  and  united  to  the  hori- 
zontal portion  by  means  of  metallic  suture. 

Kiister  deviated  somewhat  from  this  plan,  in  this,  that,  to 
prevent  subsequent  maxillaiy  anchylosis,  he  removed  the  ramus. 

Lodgraent  of  foreign  Bodies  in  the  Pharynx. — The  pharyngeal 
isthmus  is  the  site  of  lodgment  of  foreign  bodies,  which,  in 
their  transit  from  the  oral  cavity,  are  caught  and  remain  in 
this  space.  Examples  of  such  bodies  are  the  pin,  needle,  fish- 
bone or  other  sharp-pointed  object.  The  movements  of  the 
pharyngeal  walls  in  deglutition  are  such  as  often  arrest  such 
body,  and  thrust  its  point  into  the  wall  so  that  it  remains  fixed 
there.  A  pin  has  thus  been  discovered  lying  crosswise,  at  the 
entrance  of  the  oesophagus;  or  it  has  been  found  situated  verti- 
cally, in  one  of  the  crevices  or  niches  in  the  side  of  the  pharynx ; 
most  often  between  the  anterior  and  posterior  arches.  And 
sometimes,  the  object  enters  the  choanal;  and  there  it  escapes 
detection,  unless  this  space  be  specially  ex[ilored.  In  case  of 
such  accident,  aided  by  what  light  the  patient's  account  throws 
on  the  matter,  the  surgeon  must  make  a  systematic  search  of  the 
walls  and  accessory  recesses  of  the  pharyngeal  cavity,  and  if  the 
object  is  not  found,  the  finger  should  next  explore  the  parts. 

iVs  recesses  into  which  bodies  can  fall  and  elude  discovery 
are  two  pockets  which  were  described  by  Schutz,  in  1844;  these 
spaces  are  boat-shaped,  and  situated  beneath  the  tonsil;  they 
extend  downwards  and  end  on  each  side  of  the  larynx.  These 
fossse  are  bounded  behind  by  the  palato-pharyngeal  muscles;  are 
an  inch  long,  and  are  spacious  enough  to  receive  and  conceal  a 
body  as  large  as  a  cherry  seed  ;  and  if  special  search  is  not  made 
for  it,  such  object  can  remain  hidden  for  an  indefinite  time. 

When  the  body  is  found,  whether  in  open  or  secluded  site,  it  is 
usually  readily  removed  by  rheans  of  a  long  pair  of  forceps.  It 
sometimes  happens,  hovrever,  that  a  sharp-pointed  object  caught 
in  the  throat  has  pricked  or  torn  the  surface;  and  though  the 
object  is  extracted,  such  remaining  wound  makes  it  difficult  to 
■convince  the  patient  that  the  object  has  been  removed.  And  it 
may  be  added,  that  the  sensation  from  such  wound  has  often  led 


724  I'HAKYNX. 

to  a  fruitless  search  for  an  object  which  lias  been  swallowed,  or 
dislodged  from  its  pharyngeal  site. 

Hyrtl  has  directed  attention  to  certain  folds  which  lie  in  the 
pharynx  on  the  posterior  wall  of  the  larynx.  These  folds  corre- 
spond to  depressions  on  each  side,  wdiich  sink  inwards  between 
the  cricoid  and  the  thyroid  cartilages.  This  fold  reaches  from  the 
arytenoid  cartilage  to  the  end  of  the  great  horn  of  the  hyoid 
bone.  The  free  edge  of  it  is  directed  downwards  and  backwards, 
and  can  have  an  elevation  of  three  lines.  It  becomes  more  appar- 
ent when  traction  is  made  on  the  trunk  of  the  superior  laryngeal 
nerve. 

This  fold  of  mucous  membrane  does  not  obstruct  the  act  of 
swallowing;  but  it  impedes  the  free  escape  of  matter  in  the  act  of 
vomiting.  And  where  the  fold  is  of  unusual  development,  it 
may  present  an  insuperable  obstacle  to  vomiting,  as  has  been 
seen  in  some  subjects.  Sounds  which  are  passed  down  the 
pharynx  glide  easily  over  this  fold;  but  if  the  instrument  has  a 
prominence,  this  can  catch  on  the  fold  in  tlie  withdrawal  of  the 
instrument;  and  if  this  be  done  rudely,  the  fold  might  be  torn. 


CHAPTER  XXII. 


SUBLINGUAL    REGION. 


There  remains  for  consideration  only  a  small  section  of  the 
buccal  cavity,  viz.,  the  free  space  beneath  the  anterior,  or  free 
portion  of  the  tongue,  known  as  the  sublingual  space  or  region. 
This  space  is  of  greater  or  less  extent,  according  to  the  attachment 
of  the  tongue  to  the  floor  of  the  mouth.  This  space  is  invested 
with  mucous  membrane  which  abounds  in  muciparous  glands. 
Where  the  tongue  separates  from  the  floor  of  the  mouth  in  the 
median  line  lies  the  frtenum,  of  which  the  restricting  action  on 
the  lingual  movements  has  already  been  considered.  Close  to 
the  frsenum  lie  the  outlets  of  the  Whartonian  and  Rivinian 
ducts,  or  ducts  of  the  sublingual  gland.  These  outlets  are 
readily  visible  to  the  eye,  and  that  of  the  Whartonian  duct  is  so 
large  that  it  will  admit  a  small  probe. 

The  outlets  of  these  salivary  ducts  lie  in  the  summits  of 
irregularly-shaped  papillae,  which  are  vascular  and  erectile;  and 
when  the  tongue  is  uplifted,  this  erectile  action  is  visible,  while, 
at  the  same  time,  the  saliva  flows  from  or  is  ejected  from  them. 
These  papillary  bodies  may  enlarge  and  become  the  source  of 
anxiety  to  the  subject,  whose  repeated  examination  of  them  irri- 
tates and  enlarges  them.  These  enlarged  outlets  demand  no 
surgical  treatment;  the  patient  must  be  counseled  to  neglect 
them,  and,  if  possible,  to  forget  them.  The  sublingual  space,  as 
ancient  history  tells  us,  was  utilized  by  Demosthenes,  who  is  said 
to  have  placed  pebbles  in  it,  in  his  elocutionary  training;  and  in 
imitation  of  the  orator  upon  the  Crown,  to  the  writer's  knowledge, 
the  m.odern  sophomore  thus  trains  his  tripping  tongue. 

Beneath  this  space,  and  separated  from  it  by  the  mucous 
membrane,  lie  the  sublingual  gland  and  the  sublingual  bursa 
of  Fleischmann.  The  latter,  from  its  occasionally  being  the 
site  of  ranular  cyst,  demands  description,  which,  in  the  lan- 
guage of  its  discoverer,  is  as  follows:  "  If  from  one  or  the  other 

(725) 


720  srr.LiNGUAJ.  KWiiox. 

side  of  the  fraMium,  one  dissects  up  tlio  mucous  membrane,  there 
is  found  restinj^  on  the  genio-hyoglossus  muscle,  close  to  the 
frccnum,  and  behind  the  ducts  of  Wharton  and  those  of  liivin- 
ianus,  a  small  mucous  l.nirsa  divided  into  smaller  spaces  by  septa; 
this  is  the  sublingual  bursa,  the  existence  of  which  is  important 
to  know,  in  order  to  have  a  proper  knowledge  of  ranula."  This 
bursa  is  found  by  an  antero-posterior  section  of  the  floor  of  the 
mouth.  Its  origin  is  due  to  the  se})aration  of  the  lingual  mucous 
membrane  and  the  genio-hyoglossus  muscle  by  the  interposition 
of  the  sublingual  gland.  According  to  Tillaux,  this  bursal  space 
is  flat  in  form,  and  is  divided  in  the  median  line,  into  two  parts 
by  the  fraenum  ;  and  it  presents  two  faces,  the  one  attached  to  the 
floor  of  the  mouth,  and  the  other  attached  to  the  anterior  face  of 
the  genio-hyoglossus  muscle.  It  is  bounded  in  front,  and  at  the 
sides,  by  the  lower  jaw,  and  reaches  as  far  back,  on  the  sides,  as 
the  first  or  second  molar  teeth.  This  bursal  space  lies  behind  the 
sublingual  gland  and  the  duct  of  Wharton  ;  and,  according  to  the 
admeasurement  of  Tillaux,  it  is,  from  before  backwards,  nearly 
two  inches  in  length.  This  bursa  in  some  subjects,  is  traversed 
by  septa  which  divide  it  into  separate  spaces. 

Tlie  free  sublingual  portion  of  the  floor  of  the  mouth  may  be 
the  starting-point  of  epithelial  cancer,  which,  as  a  slight  erosion, 
may  appear  on  each  side  of  the  fra^num,  and  remain  there  sta- 
tionary for  a  time;  and  later,  it  may  extend  and  attack  the  tongue 
and  the  adjacent  maxilla.  Though  the  initial  point  of  disease  is 
near  the  frtenum,  it  usually  spreads  unilaterally,  rather  than 
bilaterally.  The  ulcerating  process,  in  its  extension,  finally 
attacks  the  lower  jaw  and  penetrates  the  sublingual  structures 
and  the  side  of  the  tongue;  by  metastatic  propagation,  the  disease 
travels  along  the  lymphatics  which  surround  the  duct  of  Whar- 
t<jn,  and  appears  in  the  lymphatic  glands  which  lie  next  to  the 
submaxillary  gland;  and,  finally,  the  submaxillary  gland  itself 
is  attacked.  The  sublingual  gland  also  becomes  implicated  in 
the  disease. 

The  proper  treatment  consists  in  thorough  removal  of  tlie 
aff'ected  structures.  The  knife  and  thermal  cautery  should  be 
associated  in  the  removal;  the  cautery  should  complete  the 
destruction  of  any  diseased  tissues  which  the  knife  may  have 
overlooked.  If  much  of  the  tongue  is  to  be  excised,  the  lingual 
artery  must  be  tied  as  a  preliminary  act.  To  obviate  recurrence, 
infiltrated  glands  should  be  removed,  and  also  the  submaxillary 
gland   if  it  be  indurated.      Additional   points   concerning  the 


RANULA.  727 

treatment  will  be  found  in  the  chapter  treating  of  cancer  of  the 
tongue, 

Ranula. — The  sublingual  region  is  the  frequent  site  of  a  cystic 
tumor  which  is  named  ranula.  This  term  signifies  a  small  frog; 
but  any  relationship  between  this  animal  and  the  tumor  is  a 
matter  which  the  writer  suspects  would  puzzle  anatomist,  pathol- 
ogist or  naturalist. 

The  ranula  may  vary  in  volume  from  the  size  of  a  pea  to  that 
of  an  orange.  When  small,  it  lies  superficially  beneath  the 
mucous  membrane;  but  when  large,  it  may  extend  deep  into  the 
sublingual  floor. 

Ranula,  in  reference  to  its  cause,  and  the  structures  in  which 
it  originates,  has  been  the  subject  of  thoughtful  study  on  the  part 
of  the  surgical  pathologist.  In  1850,  Haller  of  Dorpat,  wrote  a 
dissertation  on  ranula,  in  which  he  gives  the  different  opinions 
which  obtain  in  respect  to  its  origin;  and  these  he  classifies 
in  four  groups:  1.  Ranular  cyst  may  arise  from  retention  of 
saliva  in  the  sublingual  or  submaxillary  gland;  or  in  the  duct 
of  the  gland;  or  from  rupture  of  the  same  into  the  surrounding 
tissues.  2.  Or  it  may  be  a  common  cyst,  originating  as  such  do, 
elsewhere.  3.  Or  the  content  may  be  mucus,  and  arise  from  the 
retention  of  the  content  of  a  mucous  follicle.  4.  It  may  arise 
from  the  enlargement  of  the  bursa  sublingualis,  which  lies  between 
the  tongue  and  the  genio-hyoglossus  muscle. 

From  his  individual  studies,  Haller  concludes  that  the  most 
usual  mode  of  origin  is  from  the  sublingual  bursa;  and,  as  such, 
it  is  often  divided  into  separate  compartments. 

Tillaux  refers  the  usual  origin  of  ranula  to  the  sublingual 
bursa.  His  attempt  to  explain  the  rapid  appearance  of  a  large 
ranula,  as  dependent  on  augmentation  of  the  content  of  the  sub- 
lingual bursa,  is  not  convincing. 

Dassen,  in  1858,  wrote  on  ranula  and  ascribes  its  origin  to  the 
development  of  a  cyst  in  the  submucous  tissue;  and  he  asserts 
that  it  does  not  depend  on  closure  of  the  salivary  ducts,  or  of  the 
mucous  follicles. 

Besides  the  ways  enumerated  in  which  ranula  may  originate, 
the  writer  has  observed  cases  in  which  the  cyst  undoubtedly  was 
connected  with  bursse  mucosae  which  pertain  to  the  muscles 
which  lie  in  the  floor  of  the  mouth;  since,  in  the  removal  of  the 
ranula,  its  direct  connection  and  relation  with  the  sublingual 
muscles  were  verified. 

A  comparison  of  the  content  of  the  ranular  cyst  with  saliva 


728  SUBLIMJUAL    KEGION. 

has  been  made  by  means  of  cliemical  analysis.  Koiinal  saliva 
contains  an  organic  principle  named  ptyalin;  in  examination  of 
the  content  of  ranuhie  operated  on  by  U.  Weber,  he  did  not  find 
ptyalin.  Sulphocyanide  of  potassium  is  usually  found  in  saliva, 
and  is  detected  by  a  solution  of  iron,  the  union  of  the  two  giving 
a  rose-colored  reaction.  Weber  did  not  get  such  reaction  with 
ranular  content.  He  intimates,  however,  that  the  retention  of  a 
secreted  fluid,  finally  alters  its  composition;  an  example  of  which 
is  that  of  bile  retained  in  the  gall-bladder,  which  finally  loses  all 
its  normal  character.  And  by  analogy,  the  same  might  occur  in 
the  case  of  retained  saliva. 

Weber  and  others  have  sought  for  an  anatomical  connection 
between  the  ranula  and  the  ducts  of  the  sublingual  and  submax- 
illary glands;  a  probe  passed  into  the  latter  ducts  did  not  enter 
the  cyst.  Also  chewing,  which  causes  a  flow  of  saliva  from 
these  ducts,  which  is  easily  discovered  in  the  open  mouth,  does 
not  lessen  the  volume  of  a  ranula;  and,  further,  if  the  mouth  be 
so  opened  that  one  can  see  the  ducts  beneath  the  tongue,  if 
pressure  then  be  made  on  the  cyst  within  the  mouth  or  on  the 
floor  from  the  outside,  then  no  fluid  can  be  seen  exuding  from 
the  ducts,  nor  is  the  volume  lessened. 

Again,  as  proof  of  non-connection  between  the  ranular  cyst 
and  the  salivary  glands  is  the  fact  that  when  the  duct  of  the 
latter  is  opened,  or  the  gland  wounded,  the  surgeon  experiences 
o-reat  difficulty  in  closing  the  breach;  but,  on  the  contrary,  if 
such  breach  be  made  in  the  ranula,  the  difficulty  is  equally  great 
to  prevent  closure;  the  salivary  fistula  often  remains  open  despite 
all  surgical  effort;  a  breach  in  the  ranula,  with  equal  persistency, 
will  close. 

From  the  preceding  statements  it  may  be  concluded  that  the 
ranula  usually  has  origin  independent  of  the  salivary  glands; 
and  if  it  does  arise  from  the  latter,  it  is  exceptional. 

Haller  finds  that  ranula  is  definitely  limited  from  the  struc- 
tures around  it;  it  has  a  tendency  to  burst,  and  soon  to  refill 
again;  and  this  quality  to  close  and  refill  is  the  cause  of  the 
difficulty  met  in  the  attempts  to  cure  the  ranula.  And  the 
treatment  should  be  resorted  to  early,  since,  as  Allan  Burns  and 
others  have  found,  a  cure  is  far  more  easily  accomplished  then 
than  at  a  later  period.  Besides,  the  cyst  being  allowed  to  grow^ 
it  may  attain  proportions  perilous  to  life;  or  at  least  to  the  parts 
adjacent.  Thus  Ehrlich  describes  the  following  remarkable  case, 
in  the  practice  of  Cline:  "A  patient  called  to  consult  Mr.  Cline, 


EANULA.  729 

and  was  ushered  into  liis  waiting-room;  quickly  afterwards  the 
surgeon  heard  a  fall  in  his  room,  with  screams  and  groans;  and, 
on  opening  the  door,  the  patient  was  found  unconscious  and 
suffocating  on  the  floor.  Cline,  suspecting  the  cause  to  be  a  foreign 
body  in  the  windpipe,  was  proceeding  to  perform  tracheotomy, 
when  lie  perceived  that  the  man's  tongue  was  crowded  backwards 
by  a  ranula;  he  plunged  a  lance  into  this  and  gave  relief  by 
giving  vent  to  a  large  cjuantity  of  pus  and  lymph."  And  in  the 
records  of  the  Society  of  Surger}^  in  Paris,  there  is  described  a 
ranula  which  had  grown  to  such  dimensions  as  to  displace  the 
teeth.  To  prevent  such  disaster  as  here  mentioned,  early  inter- 
vention is  prudent.  For  the  cure  many  methods  have  been 
announced,  of  which  a  review  here  follows. 

Pare  and  Tulpius  opened  the  cyst  and  then  applied  a  hot  iron 
to  its  surface.  Dionis  opened  and  touched  the  inner  surface  with 
sulphuric  acid.  Jobert  first  dissected  the  mucous  membrane 
from  the  cyst,  and  then  he  split  the  latter  transversely,  and 
drawing  the  posterior  portion  backwards  towards  the  tongue,  he 
stitched  it  there;  and  the  anterior  portion  was  pulled  forwards 
and  fixed  there  by  a  suture.  In  this  way  the  cyst  is  maintained 
open,  and  not  being  able  to  refill,  a  cure  is  effected.  Petrequin 
cured  ranula  by  passing  a  leaden  suture  through  it  and  allowing 
this  to  remain  in  place  until  the  cystic  cavity  contracted  and  a 
cure  was  obtained.  Haller  thinks  tlie  best  methods  are  those  in 
which  an  inflammation  is  excited;  and  this  may  be  done  by 
cauterization  with  the  hot  iron  or  seton,  or  by  the  injection  of 
irritant  agents.  In  a  case  treated  by  Pisani,  in  which  incision, 
excision,  suture  of  the  walls  and  injection  of  irritating  substances 
had  failed,  a  resort  was  had  to  the  introduction  of  a  gold  tube, 
which,  being  retained  in  place  for  years,  finally  eflfected  a  cure. 
Gosselin  cured  ranula  by  removing  a  large  portion  of  the  outer 
wall,  and  then  cauterizing  the  interior  surface  with  nitrate  of 
silver;  this  cauterization  was  repeated  every  third  day,  and,  thus 
proceeding,  a  cure  was  reached. 

Paulli  makes  two  classes  of  ranula:  a  primary  and  a  second- 
ary form;  the  primary  is  superficial,  and  seated  on  each  side  of 
the  frsenum;  while  the  secondary  form  arises  from  the  rupture 
of  the  primary  one,  and  this  may  penetrate  the  floor  of  the 
mouth,  in  its  growth,  and  at  length  reach  and  rest  on  the  tendon 
of  the  digastric  muscle.  As  means  of  treatment,  he  advises  the 
injection  of  tincture  of  iodine,  which,  in  curing  the  cyst,  may 
also  induce  atrophy  of  the  submaxillary  gland.  Paulli  mentions 
47 


/oO  SUBLINOrAL    REGION. 

that  Dupuytren  ourod  ranula  by  the  introduction  of  a  small 
hollow  cylinder  into  the  cyst;  instead  of  tliis  Paulli  inserted  a 
ring  that  could  be  tij^htened  or  enlarged.  The  ring  being  jtlaced 
in  tlie  cystic  cavity,  it  causes  an  irritation,  and  granulations  grow 
over  and  about  it;  and  these  must  occasionally  be  removed. 

Bryk,  from  tlie  observation  of  nineteen  cases  of  ranula,  finds 
a  not  infrequent  cause  to  be  some  inflammatory  affection  of  the 
floor  of  the  mouth,  especially  dental  disease;  and  he  makes  three 
classes  of  the  alfection,  viz.,  sublingual,  submaxillary  and  retro- 
maxillary.  His  treatment  consists  of  the  seton,  which  is  passed 
through  the  ranula,  and  allowed  to  remain  there ;  or  tlie  work 
may  be  done  by  cauterizing  with  the  galvano-cautery,  tlie  wire  of 
which  is  passed  through  the  cyst. 

Michel,  of  Nancy,  reports  six  operations  for  the  cure  of  ranula, 
in  which  the  cyst  was  dissected  out  from  the  floor  of  the  mouth  : 
in  five  of  these  cases  he  first  slit  the  sack  and  then  dissected  out 
the  parts;  in  the  sixth  case  he  dissected  out  the  cyst  without 
opening  it.  This  radical  treatment  has  been  tried  by  the  Avriter, 
yet  the  disease  returned,  due  probably  to  imperfect  dissection. 
In  two  cases  the  author  stuffed  the  cysts  with  powdered  capsicum ; 
in  one  a  cure  was  obtained;  in  the  other  the  ranula  reappeared, 
but  was  finally  cured  by  repeated  excision  of  portions  of  the 
cystic  wall. 

As  an  epitomized  summary  of  means  which  may  be  resorted 
to,  the  following  is  offered:  open  and  pencil  the  inner  surface 
with  a  strong  tincture  of  iodine,  or  with  a  strong  solution  of 
nitrate  of  silver,  or  chloride  of  zinc;  forty  grains  to  the  ounce  of 
either  of  these  agents  would  be  of  sufficient  strength.  This 
escharotic  application  should  be  used  every  second  day  until  its 
action  has  been  tested;  and,  in  case  of  failure,  try  the  thermal 
cautery.  Should  failure  attend  all  these  modes  of  treatment,  then 
resort  to  excision,  partial  or  total.  To  perform  such  extiri)ation 
through  the  mouth  is  attended  with  much  difficulty,  and  there 
is  also  danger  of  wounding  vessels;  to  avoid  these  difficulties  the 
work  of  removal  may  be  done  through  the  floor  of  the  mouth. 
For  this,  let  an  antero-posterior  cut  be  made  through  the  skin 
in  the  median  line,  and  then,  with  a  blunt  dissector,  separate 
the  genio-ln'oid  and  genio-hyoglossi  muscles;  thusthecyst  might 
be  reached  and  enucleated;  injured  vessels  could  be  tied  and 
drainage  easily  provided  for,  and  the  work  done,  possibly,  with- 
out entering  the  oral  cavity. 

In  closing  the  chapter  on  ranula,  reference  should  be  made  to 


EAXULA.  731 

three  bursee  described  by  Yerneuil,  and  which,  when  enlarged, 
may  be  named  pseudo-ranuhe.  1.  The  ante-thyroid  bursa,  which 
is  subcutaneous  and  hes  in  front  of  the  tLyroid  cartilage;  and 
this  cavity  can  communicate  with  a  similar  one  which  is  situated 
behind  the  origin  of  the  sterno-thyroid  muscles.  2.  A  deep  sub- 
hyoid bursa  which  arises  through  the  friction  of  the  hyoid  bone 
against  the  upper  margin  of  the  thyroid  cartilage;  and  this  sub- 
hyoid bursa  may  be  divided  by  a  septum  mto  two  smaller  cavi- 
ties. This  bursa  may  enlarge  and  then  extend  under  the  hyoid 
bone.  Verneuil  claims  that  the  sub-hyoid  ranula  of  Xelaton,  in 
place  of  originating  from  enlarged  sublingual  mucous  glands, 
arises  from  dropsy  of  the  hyo-thyroidean  bursa.  3.  A  supra- 
hyoid bursa,  which  is  only  exceptionally  seen;  this  is  bounded 
above  and  behind  by  the  genio-hyoglossi  muscles. 

Verneuil  combats  the  opinion  of  Xelaton  that  the  sublingual 
mucous  glands  can,  by  abnormal  growth,  penetrate  the  sublingual 
structures,  and,  finally,  appear  under  the  chin;  for  such  a  develop- 
ment would  be  arrested  by  the  dense  glosso-epiglottic,  hyo- 
epiglottic,  and  hyo  thyroid  membranes;  and  hence  he  claims 
that,  should  the  foregoing  btirsa  enlarge,  the  resulting  cyst  should 
not  be  included  under  the  head  of  ranula. 

The  writer  has  observed  and  treated  cases  of  the  bursal  cyst 
here  described.  The  surest  means  of  cure  is  to  dissect  out  the 
cj'st;  and  in  doing  this,  unless  the  work  be  done  with  much  care. 
the  scalpel  can  penetrate  the  lan,'ngo-pharyngeal  cavity,  and 
seriously  complicate  the  recovery.  A  means  of  treatment  unat- 
tended by  the  risk  mentioned,  would  be  to  evacuate  the  content, 
and  inject  tincture  of  iodine  into  the  cavity.  And,  as  occurs  in 
similar  treatment  of  liydrocele,  it  may  be  necessary  to  repeat  tliis 
procedure  two  or  three  times. 


CHAPTER  XXIII. 


MAXILLA    INFERIOR. 


The  function  of  tlie  lower  jaw  is  to  contain  and  retain  in 
place  one-half  of  the  teeth;  and,  through  the  medium  of  eight 
muscles,  it  becomes  the  instrument  by  which  mastication  is 
accomplished;  for  the  upper  jaw  is  motionless  in  the  acts  of  chew- 
ing, while  the  lower  one  is  the  sole  factor  of  these  movements. 
This  important  function  must  be  borne  in  mind  in  the  treatment 
of  maxillary  luxation  and  fracture,  and  in  all  operations  in 
which  the  continuity  of  the  bone  is  broken. 

Surgical  Anatomy. — Certain  landmarks  demand  the  attention 
of  the  surgeon,  and  should  be  accurately  known;  these  are  the 
mental  foramen,  the  depression  for  the  facial  artery,  the  inferior 
dental  foramen,  with  the  prominence  of  Spix,  and  tlie  cond3'le. 

The  mental  foramen,  through  whicli  escapes  the  terminal 
portion  of  the  inferior  dental  nerve,  is  situated  near  the  middle 
of  the  central  portion  of  the  body  of  the  lower  jaw,  or  beneath 
tlie  second  bicuspid  tooth  (Despres).  In  the  maturity  of  adult 
life  this  foramen  lies  midway  between  the  upper  and  lower  mar- 
gins; but  as  the  form  of  the  jaw  is  changed  under  the  wasting 
agency  of  years,  this  opening  finally  becomes  situated  much 
nearer  the  upper  than  the  lower  margin.  It  lies  in  the  continua- 
tion of  a  straight  line  which  passes  through  the  supra-orbital 
and  the  infra-orbital  foramina. 

On  the  outside  of  the  body  of  the  lower  jaw,  near  its  union 
with  the  ramus,  and  nearly  an  inch  from  the  posterior  margin  of 
the  angle,  there  is  a  depression  in  which  lies  tlie  facial  artery 
with  its  accompanying  veins;  and  this  point  is  sometimes  utilized 
for  compresj^ing  the  vessel,  when  incisions  are  made  which  may 
open  the  labial  vessels.     This  depression  becomes  greater  with  age. 

In  the  middle  of  the  lower  portion  of  the  ramus  of  the  jaw  lies, 
on  the  inside,  an  opening  for  the  entrance  of  the  inferior  dental 
nerve.  This  opening  lies  at  the  point  of  intersection  of  two  lines, 
(732) 


CONGEXITAL  DEFORMITY.  733 

one  of  which  lies  in  the  median  line  of  the  ramus,  while  the  other 
is  in  the  median  line  of  the  hody ;  and  such  point  of  intersection 
corresponds  to  the  axis  of  motion  of  the  jaw  in  its  upward  and 
downward  movements;  and  in  such  axis  the  nerve,  as  Hyrtl 
points  out,  is  absolutely  free  from  any  pulling  or  stretching.  A 
prominence  exists  on  the  lower  edge  of  this  foramen,  known  as 
the  eminence  of  Spix,  which  may  guide  the  searcher  for  the  nerve 
in  the  operation  of  neurectomy. 

Another  important  landmark  is  the  condyle  of  the  lower 
jaw,  which  lies  in  front  of  and  close  to  the  tragus.  This  rounded 
eminence  is  easily  felt  through  the  integument;  and  when  the 
mouth  is  being  opened,  the  condyle  can  be  felt  moving  forwards; 
and  as  it  does  so,  it  becomes  more  prominent. 

Between  the  cond3de  and  the  temporal  bone  is  interposed  an 
interarticular  cartilage,  of  meniscoid  form.  The  condyle  has 
intimate  relations  with  the  branches  of  the  internal  maxillary 
artery  and  the  accompanying  veins;  and  these  vessels  may 
bleed  freely  if  wounded  in  disarticulating  the  ramus  of  the 
jaw. 

The  maxilla  inferior  has  only  a  limited  range  of  movement, 
being  arrested  by  the  upper  jaw  above;  and  muscles  and  liga- 
ments limit  descent  downwards. 

The  low^er  jaw,  in  its  work,  is  an  example  of  a  lever  of  the 
third  order;  and  in  mastication,  the  work  done  by  the  incis- 
ors requires  more  power  than  that  done  by  the  molars.  The 
reverse  of  this  obtains  in  forcibly  depressing  the  jaw,  when 
less  power  is  needed  in  front  than  if  the  work  be  done  further 
backwards. 

Congenital  Deformity. — The  lower  jaw  is  the  subject  of  con- 
genital defect  and -deformity,  which  have  been  studied  by  Ogston, 
who,  in  1873,  wrote  on  this  subject.  His  classification  is  as  fol- 
lows: (1)  entire  absence  of  the  lower  jaw;  (2)  unusual  size  of 
the  jaw;  (3)  unusual  smallness  of  the  jaw  in  its  entirety;  (4) 
abnormal  smallness  on  one  side.  He  finds  that  such  deformities 
are  rare.  Entire  absence  of  the  bone  has  only  been  seen  among 
animals.  Enormous  largeness  is  rare,  and,  when  present,  is 
associated  with  defect  of  other  bones.  Abnormal  smallness  is 
likewise  associated  with  other  kindred  deformities;  unilateral 
smallness  is  associated  with  other  asymetrical  conditions  of  the 
skull;  and,  finally,  the  temporo-maxillary  joint  may  be  absent. 
Congenital  luxation  of  the  jaw  is  a  rare  occurrence. 

Alveolar  Periostitis,  Gingivitis,  and  dental  Abscess. — The  periosteal 


734  MAXILLA    JNl-KKIOR. 

and  mucous  tegumeiitary  tissues  of  the  alveolar  process  of  the 
lower  jaw  are  the  occasional  site  of  inflammation.  Since  a  sim- 
ilar process  occurs  in  the  alveolar  i)rocess  of  the  upper  jaw,  a 
description  of  the  affections  in  the  one  jaw  applies  to  those  of 
the  otlier.  As  to  the  nomenclature,  the  term  parulis  is  used  to 
denote  this  disease. 

As  causes  of  parulis  may  be  mentioned  dental  disease,  in 
which  one  or  more  teeth  may  be  affected,  disease  of  the  osse- 
ous alveolar  structure,  or  a  wound  of  the  gingival  structure 
itself  The  affection  may  be  seated  on  a  small  portion  of  the 
alveolar  process;  or  a  very  large  portion  may  be  implicated. 
The  writer  has  observed  it  oftenest  in  the  upper  incisor  region ; 
though,  not  infrequently,  it  appears  near  the  lower  molar  teeth. 

The  inflammation  may  commence  in  the  gingival  ti.ssue,  and 
thence  reach  and  attack  the  periosteum;  or,  commencing  in  the 
bone,  it  may  pass  to  the  mucous  membrane.  It  may  be  on  the 
inner  or  the  outer  side  of  the  maxillary  arch;  or  both  sides  may 
be  simultaneously  inflamed.  And  whether  it  begins  centrally 
or  superficially,  at  first  the  gingival  tissue  swells,  is  hard,  and  is 
intensely  red.  There  is  pain  of  a  throbbing  character,  which  is 
usually  continuous;  and  this  may  be  felt  in  a  field  which  is 
much  greater  than  the  affected  structure. 

After  a  few  days  of  tormenting  annoyance  to  the  patient, 
suppuration  supervenes;  pus  forms  on  or  near  the  bone,  and 
commonly  detaches,  for  a  short  space,  the  soft  parts  from  the 
bone;  and  thus  arises  an  abscess,  of  which  the  purulent  content 
can  be  detected  by  the  trained  finger. 

As  just  traced,  such  is  the  cause  of  an  acute  gingivitis  ending 
in  suppuration;  a  form,  more  slow  in  its  march,  is  sometimes 
met,  in  which  the  causal  agency  is  dental  caries  or  disease  of  a 
limited  portion  of  the  alveolar  process.  This  form  may  have  a 
course  which  may  continue  indefinitely  long;  in  its  duration, 
years  are  often  counted.  The  abscess  which  here  forms,  opens, 
and  there  remains  a  narrow  passage  or  fistulous  canal,  which, 
traversing  the  soft  parts,  reaches  to,  and  penetrates  into,  or 
passes  quite  through  the  alveolar  process. 

Treatment.— The  treatment  proper  for  the  acute  form  differs 
from  that  required  in  the  chronic;  for  the  former,  seek  for  the 
causal  agency  and  remove  that.  But  the  all-important  thing  to  be 
done  is  to  combat  the  disease  in  its  early  stage,  by  freely  scarify- 
ing the  inflamed  structures,  and  thus  permitting  the  congested, 
stagnating  blood  to  escape.     The  incisions  should  be  made  with 


ALVEOLAR    PERIOSTITIS    AND    DENTAL    ABSCESS.  735 

a  knife  which  is  faultlessly  sharp,  and  when  the  bleeding  has 
ceased,  the  affected  part  should  be  painted  with  a  mixture  com- 
posed of  equal  parts  of  tincture  of  iodine  and  tincture  of  nut- 
galls.  Intervention  in  this  manner,  at  an  early  period,  may 
intercept  and  avert  the  approaching  suppuration;  but,  as  a  rule, 
the  patient  allows  this  desirable  opportunity  to  escape:  the  case 
usually  has  reached  the  suppurative  stage  when  it  is  first  seen; 
and,  as  already  said,  the  experienced  touch  can  distinguish  the 
liquid  content  beneath,  or  within  the  tumefied  structure.  The 
proper  management  here,  is  to  lay  the  abscess  open,  so  that  the 
purulent  content  of  the  abscess  and  the  blood  in  its  walls  may 
have  ready  escape;  and  to  effect  this,  the  incision  must  be  free, 
and  reach  to  the  bottom  of  the  abscess,  even  to  the  roots  of  the 
teeth,  whether  the  disease  be  on  the  upper  or  on  the  lower 
jaw.  Thus,  the  abscess  may  easily  be  cured  in  most  cases;  but 
if  the  causal  agency  be  dental  or  alveolar  caries,  or  necrosis, 
the  evacuation  of  the  abscess  gives  but  temporary  relief,  since 
there  w411  afterwards  remain  a  fistulous  opening  which  will  have 
indefinite  continuance;  and  in  its  course,  it  will  present  alterna- 
tions of  closing,  filling  with  pus,  and  reopening.  The  disease  has 
now  assumed  the  character  of  chronic  abscess  communicating 
with  the  surface  by  means  of  a  fistula  which,  according  as  it  is 
located,  may  be  named  a  dental  or  alveolar  fistula. 

The  dental  fistula  is  preceded  by  an  abscess,  commonly  of 
chronic  development.  The  pus  which  forms  on  the  alveolar 
process  may  open  inwards  towards  the  tongue;  or  outwards 
between  the  lip  or  cheek,  and  the  alveolar  arch ;  or  it  may  pierce 
the  lip,  or  cheek,  and  then  appear  on  the  outside  of  the  attached 
portion  of  the  lip,  or  on  the  cheek;  or,  after  perforating  the  floor 
of  the  mouth,  it  may  open  through  the  skin  behind  the  chin. 
Exceptionally,  such  pus  has  gravitated  and  api^eared  on  the 
front  of  the  neck.  Around  such  fistulous  passage,  the  tissues  are 
cicatricially  contracted,  and  are  usually  depressed  towards  the 
site  of  the  dental  or  alveolar  disease,  whence  the  pus  arises. 
Such  fistula  penetrates  the  bone,  and  may  completel}^  traverse 
the  alveolar  process.  Or  the  disease  may  extend  into  the  body  of 
the  bone,  whether  this  be  the  upper  or  lower  jaw.  Su23purative 
disease  of  the  antrum  has  found  an  outlet  below,  and  resembled 
alveolar  or  dental  fistula.  One  of  the  worst  cases  of  alveolar 
fistula  treated  by  the  writer  had  its  origin  in  an  imperfectl}' 
evolved  incisor  tooth.  A  large  portion  of  the  premaxillary  bone, 
in   which   the   tooth   was   obliquely  fixed,   became   the   site  of 


730  MAXILLA    IXrKKIOK. 

destructive  caries.  Such  fistula  has  been  observed  by  the  writer 
located  in  the  lower  jaw,  and  situated  near  the  symphysis;  and 
in  two  cases  of  the  kind,  the  osseous  disease  reached  almost 
through  the  bone,  antero-posteriorly.  The  cutaneous  of)enino- 
would  occasionally  close,  and  afterwards,  when  i)us  reformed,  the 
sinus  reopened  externally. 

The  dental  or  alveolar  tistula  is  nearly  jiainless,  unless  it 
•should  be  so  placed  as  to  implicate  the  dental  nerve;  the  cliief 
trouble  from  it  is  the  occasional  purulent  discharge;  and  it  may 
further  disturb  the  patient  by  causing  some  deformity  when  it 
has  a  cutaneous  opening. 

Treatment. — In  those  cases  in  which  the  affection  primally 
originates  in  a  decayed  tooth,  the  latter  should  be  extracted;  but 
if  the  fistula  has  arisen  from  a  limited  caries  of  tiie  maxilla,  then 
to  radically  cure,  the  carious  structure  must  be  removed.  For 
this  work,  a  scalpel,  small  trephine,  curette  and  small  chisel  are 
required.  When  practicable,  let  the  work  be  done  within  the 
oral  cavity;  even  when  the  fistula  opens  through  the  skin  remote 
from  the  affected  bone,  it  is  possible,  in  ahiiost  every  case,  to 
detach  the  labial  or  buccal  structure  from  the  alveolar  process, 
and  find  the  affected  point  of  bone  within  the  mouth.  The  soft 
parts  are  now  to  be  uplifted  from  the  bone;  and  when  the  diseased 
structure  is  tlius  brought  into  full  view,  a  trephine,  of  three  lines 
diameter,  is  to  be  placed  on  the  site  of  disease,  and  a  circular 
section  of  bone  around  the  fistula  thus  removed.  Care  must  be 
taken  that  the  trephine  includes  all  the  diseased  bone:  both 
laterally  and  in  depth.  All  irregularities  of  surface  are  to  be 
scraped  or  rasped  off.  After  this,  the  adjacent  soft  parts  are  to  be 
brought  over  the  breach,  and,  if  necessary,  fixed  there  by  a  suture. 
This  exsection  may  be  done  with  a  gouge  or  a  round-edged 
chisel;  yet  done  in  the  latter  way,  some  affected  structure  is  more 
easily  overlooked  than  if  one  first  circumscribes  the  whole  with 
the  trephining  crown. 

xVfter  the  bone  has  been  thus  excised,  the  walls  of  the  fistula 
must  be  trimmed,  and  the  wounded  surfaces  so  opposed  and 
sutured  as  to  efface,  as  much  as  possible,  the  preexisting 
deformity. 

By  the  treatment,  as  detailed,  of  the  maxillary  fistula,  whether 
dental,  alveolar,  or  situated  in  the  body  of  the  jaw,  an  affection 
may  be  gotten  rid  of  in  a  few  days,  which  has  worried  the  patient 
for  years. 

Wisdom  Teeth. — The  eruption  of  the  posterior  molar  teeth,  the 


WISDOM    TEETPI.  737 

so-named  luisdoni  teeth,  is  often  accompanied  by  great  trouble  to 
the  patient;  and  tliis  is  limited  almost  wholly  to  those  of  the 
inferior  maxilla.  This  trouble  may  arise  from  the  mal-position 
and  ill-direction  in  which  the  teeth  grow;  or  it  may  arise  from 
the  want  of  room  for  the  appearance  of  this  the  last  member  of 
the  dental  family. 

Where  the  germ  of  the  tooth  is  situated  abnormally,  as  the 
dental  crown  develops,  it  may  impinge  against  the  adjacent 
tooth,  or  the  front  edge  of  the  ramus;  or  be  directed  against  the 
walls  of  the  alveolus  on  the  inner  or  outer  side.  Thus  ill-placed, 
the  growing  tooth  causes  pain ;  and  this  pain  is  the  most  excru- 
ciating when  the  crown  is  deflected  towards  the  ramus.  The 
worst  condition  is  that  in  which  the  dental  crown  is  so  situated 
beneath  tlie  margin  of  the  ramus  that  it  cannot  appear  in  the 
oral  cavity;  then,  through  pressure,  it  bores  itself  a  way  into  the 
bone;  or,  if  there  be  partial  space  for  its  appearance,  it  separates 
and  uplifts  the  soft  parts  from  the  margin  of  the  ramus;  and 
these  soft  parts  are  maintained  in  a  state  of  painful  ulceration. 
Should  there  be  ample  space  for  the  appearance  of  the  tooth,  the 
process  of  its  eruption  will  be  of  transient  duration,  and  the  pain 
from  it  will  be  slight. 

This  dental  trouble,  in  the  cases  in  which  some  abnormal 
condition  impedes  the  eruption  of  the  tooth,  announces  itself  by 
tumefaction  of  the  superjacent  or  adjacent  soft  parts;  the  gingi- 
val tissue  is  red  and  painful;  and  there  is  a  pseudo-trismus 
present,  in  wdiich  the  temporal  and  masseter  muscles  are  con- 
tracted and  fix  the  lower  jaw  nearly  immovably  against  the 
upper  one.  The  swelling  may  extend  and  appear  on  the  outside, 
near  the  angle  of  the  jaw;  and  the  lymphatic  glands  of  the  region 
may  also  swell.  The  affection  finally  ends  in  suppuration  of 
the  affected  gingival  structure;  and  in  severe  cases,  this  ma}^ 
involve  the  adjacent  soft  parts.  Where  the  tooth  is  imprisoned 
beneath  the  border  of  the  ramus,  or,  by  ill-position,  it  is  deflected 
from  the  normal  outlet,  in  such  cases  there  occurs  alveolar 
necrosis,  on  a  larger  or  smaller  scale.  This  osseous  disease 
aggravates  that  of  the  soft  part,  so  that,  in  the  latter,  the  suppura- 
tive action  may  traverse  the  soft  parts  and  appear  on  the  outside. 
The  aff'ection  is  rarely  of  so  grave  a  character  as  this;  in  the  cases 
in  which  surgical  assistance  is  usually  sought,  the  tooth  merel}^ 
crowds  against  the  neighboring  tissues,  and,  uplifting  these, 
maintains  in  them  a  painful  ulceration,  which  may  continue  for 
many  weeks. 


/OO  MAXIKLA    IXFKKIOK. 

Ti'caimoit. — The  luanagement  of  such  affection  is  determined 
by  the  causal  agency  and  tlie  resuUant  conditions.  In  the  milder 
and  usual  form,  relief  will  be  obtained  by  catching  with  toothed 
forceps  the  tissue  'wiiieh  is  ]»ressed  open,  and  cutting  this  off  with 
scissors.  But  to  do  this,  the  mouth  must  first  be  opened,  and 
retained  so.  This  may  be  done  in  one  of  the  ways  which  the 
writer  has  described,  when  treating  of  operations  on  the  tonsil; 
and  in  the  absence  of  a  specially  devised  instrument,  a  piece  of 
wood  of  wedge-shape  ma}'  be  pushed  between  tiie  upi)er  and 
lower  molar  teeth;  and  to  assist  in  opening  the  mouth,  let  grad- 
ual downward  pressure  be  made  on  the  chin. 

If  the  trouble  be  of  a  sererer  grade,  of  the  form  in  which  there 
is  insufficient  space  for  the  eruption  of  the  tooth,  if  the  crown  has 
so  appeared  that  a  dental  forceps  can  seize  it,  let  it  be  extracted  ; 
but  if  the  crown  be  inaccessible,  then  the  next  preceding  molar 
tooth  may  be  removed.  Though  this  practice  has  the  sanction 
of  high  authority,  it  should  not  be  resorted  to  until  reasonable 
effort  has  failed  to  get  rid  of  the  real  offender.  For  example,  by 
the  aid  of  scissors  and  cutting  forceps,  the  soft  tissues  and  the 
bony  structures  can  be  so  opened  that  the  tooth  can  be  exposed, 
and  drawn;  and  though  this  work  may  cost  the  patient  much 
pain,  yet  he  wall  have  ample  recompense  in  preserving  the  pre- 
ceding molar,  which  will  remain  with  liim  as  a  lifelong  friend; 
while  the  M'isdom  tooth  is  often  only  a  transient  sojourner,  and, 
during  its  stay,  is  often  the  occasion  of  so  much  annoyance, 
that  it  will  1)0  a  real  boon  when  the  cycle  of  evolution  is  com- 
pleted which  is  destined  to  omit  this  tooth  from  man's  mouth. 

In  case  the  dens  sapiens  is  so  ill-placed  that  it  cannot  escape 
from  its  alveolar  prison,  then  a  dental  cyst  or  partial  maxillary 
necrosis  may  result;  and  in  such  condition,  operative  interven- 
tion, adapted  to  the  conditions  present,  must  be  resorted  to;  and 
if  possible,  this  should  be  done  within  the  buccal  cavit}^;  but  if 
this  be  impracticable,  then  an  opening  should  be  made  around 
the  angle  of  the  jaw,  the  soft  parts  reflected  upwards  and  for- 
wards, and  the  disease  reached  and  removed. 

Necrosis  of  the  Lower  Jaw. — The  immediate  or  direct  cause  of 
necrosis  of  the  inferior  maxilla  (and  this  applies  equally  well  to 
the  upper  jaw)  is  inflammatory  action  ending  in  the  formation 
of  pus  next  to,  or  within  the  bone;  and  such  inflammation  is 
located  in  the  periosteum.  The  necrosis  may  be  partial,  and 
limited  to  the  outer  lamella  of  the  bone;  or  it  may  involve  the 
entire  thickness  of  the  bone;  and  in  the  latter  case,  a  large  por- 
tion, or  the  entirety  of  the  maxilla  may  die. 


NECROSIS    OF    THE    LOWER   JAW.  739 

Along  with  the  work  of  necrosis,  tlie  ^jrocess  of  repair  is  like- 
wise present,  and  new  bone  in  diverse  forms  may  be  produced; 
for  example,  this  can  grow  in  regular  lamellated  form,  of  even, 
regular  surface,  and  this  may  be  as  thick  as  the  normal  structure; 
or  it  may  be  of  paper-like  tenuity;  and  the  whole  may  be  a 
complete  model,  and  an  analogue  of  the  necrosing  maxilla, 
which  it  surrounds.  The  site  of  this  new  bone  is  exterior  to  the 
original  maxilla,  and  it  is  produced  from  the  inner  face  of  the 
2')eriosteal  membrane;  one  isolated  case  is  reported  of  reproduc- 
tion of  maxillary  structure  from  the  outer  face  of  the  periosteum. 
Instead  of  a  regular  osseous  envelope  of  the  form  mentioned,  the 
new  growth  may  occur  irregularly  in  the  form  named  osteophytes; 
the  mineralogical  term  stalactite  is  sometimes  used  to  designate 
this  formation.  These  osseous  growths  in  spine-form  or  crest- 
like ridges,  originate  from  isolated  sections  of  periosteum  which, 
from  some  exciting  cause,  are  stimulated  to  excessive  osteo-genetic 
activity. 

The  reproduction  of  bone  in  case  of  maxillary  periostitis  does 
not  invariably  occur;  the  inferior  maxilla  has  been  known  to 
die,  and  no  new  osseous  structure  has  replaced  it.  The  writer  has 
seen  this  wliere  a  portion  of  the  lower  jaw  had  been  lost  b}' 
necrosis.  Such  defect  in  reproduction  is  fortunately  not  the  rule ; 
and  where  restorative  material  is  nearly  or  quite  absent,  it  will 
usually  be  learned  in  the  history  of  t]ie  case,  that  new  bone  has 
been  formed,  and  afterwards  it  vanishes  through  absorption: 
especially,  if  the  dead  sequestrum  has  been  removed  prematurely. 
The  reproductive  force  seems  feeblest  at  the  angle  of  the  lower 
jaw,  and  in  the  coronoid  and  condyloid  process;  and  this  may 
be  accounted  for  in  the  first  and  second  of  the  sites  mentioned,  by 
the  periosteal  covering  being  replaced  by  the  insertion  of  muscles. 
Where  the  outer  thickness  of  the  bone  is  restored,  there  is  absence 
of  the  inferior  dental  canal. 

Necrosis  of  the  inferior  maxilla,  though  it  may  occur  at  any 
point,  appears  oftenest  in  the  middle  third  of  the  horizontal  por- 
tion of  the  bone:  viz.,  in  the  part  subjacent  to  the  molar  teetli. 
As  the  disease  advances,  the  teeth  above  may  fall  out,  and 
the  dead  bone  be  exposed  to  touch  and  site;  and  then  the 
necrosed  bone  lies,  as  it  were,  in  a  trough,  of  which  the  bottom 
and  sides  consist  of  the  normal  bone  thickened  by  new  structure. 
Instead  of  opening  into  the  mouth,  the  suppurative  process  may 
perforate  the  floor  of  the  mouth  and  appear  near  the  margin  of 
the  lower  jaw;  and  the  outlet  is  often  near  the  angle  of  the  jaw. 


<40  MAX  1 1. 1. A    INTKIUOR. 

Such  external  opening  lasts  indefinitely  long,  and  soon  becomes 
bounded  by  an  uplifted  fringe-like  border  of  granulative  tissue; 
and  if  it  be  explored  with  a  sound,  tlie  instrument  will  detect 
dead  bone  at  the  bottom  of  the  fistulous  sinus. 

Such  necrosis  is  the  special  appanage  of  childhood;  and 
frequently  dates  from  the  advent  of  second  dentition;  yet  no  age 
is  exempt  from  it.  The  following  may  be  mentioned  as  the  chief 
causal  agencies  in  its  production:  (1)  Dental  caries,  and  irregular 
development  of  the  roots  of  the  teeth;  and  such  irregularity  may 
consist  in  a  mal-position,  in  which,  the  root  deviating  from  its 
normal  site,  encroaclies  on  the  maxillary  structure;  and  sucli 
encroachment  can  arise  from  both  the  radical  and  coronal  portion 
of  the  teeth.  Also,  it  is  probable  that  from  abnormal  closeness 
of  the  developing  teeth,  the  inter-dental  alveolar  structure  may 
die  from  the  com[)ression.  (2)  Dental  caries  may  arise  from 
mercury  and  phosphorus;  and  it  has  been  claimed  that  arsenical 
fumes  can  cause  maxillary  necrosis.  The  grinder  of  pearl-shell 
has  been  observed  to  become  the  victim  of  such  necrosis.  The 
necrosis  arising  from  phosphorus  will  be  treated  of  in  another 
cliapter.  (3)  Certain  constitutional  diseases  may  have  maxillary 
necrosis  as  a  complication;  thus  it  may  arise  from  syphilis, 
scrofula,  scorbutus,  rheumatism,  measles,  smallpox,  scarlet  fever 
and  typhoid  fever.  The  writer  has  seen  cases  of  maxillary 
necrosis  from  syphilis;  this  is  rarer  in  the  lower  than  in  the 
upper  jaw.  As  a  remote  sequel  of  measles  and  scarlet  fever,  the 
writer  has  observed  a  few  cases.  (4)  Some  inflammatory  affec- 
tion of  the  mouth  of  a  gangrenous  character  may  cause  necrosis; 
thus  from  noma  the  writer  has  seen  the  death  of  the  cheek 
reach  into  and  implicate  the  adjacent  jaw;  in  such  cases,  death 
usually  relieves  the  surgeon  of  attention  to  the  necrosis. 

Necrosis,  on  a  large  scale,  occurs  much  oftener  in  the  lower 
than  in  the  upper  jaw;  and  this  is  explicable  from  the  fact  that 
the  position  of  the  lower  jaw  is  such  that  it  favors  the  lodgment 
on,  and  gravitation  into  its  structure  of  morbific  materials. 

Cotemporaneous  with  the  appearance  of  suppuration,  the 
affected  part  becomes  larger;  and  this,  primarily,  is  due  to  thick- 
ening of  the  periosteum;  and  subsequently,  to  the  production  of 
bone  on  the  inner  face  of  the  affected  periosteum;  and  lience  such 
swelling  with  suppuration  becomes  one  of  the  surest  signs  of 
the  necrosis;  and  the  nature  of  this  disease  is  clearly  established 
when  a  fistulous  o])ening  forms  through  which  a  probe  can  be 
passed  to  the  dead  bone. 


NECROSIS    OF    THE    LOWER    JAW.  741 

Tlie  duration  of  maxillary  necrosis  varies  according  to  the 
part  of  the  bone  which  is  affected.  When  the  necrosis  is  located 
in,  and  limited  to,  the  alveolar  process,  the  course  is  a  brief  one; 
death  and  detachment  of  the  part  affected  can  occur  within  a 
few  months.  And  where  the  causal  agency  is  some  exanthema- 
tous  disease,  the  course  is  a  rapid  one;  here  the  immediate  cause 
is,  jjrobably,  an  embolic  closure  of  the  nutrient  vessel  of  the  part; 
and  a  portion  of  bone,  being  thus  deprived  of  nutrition,  it  quickly 
dies.  In  all  cases,  in  which  there  is  death  of  the  entire  thick- 
ness of  the  bone,  the  work  of  separation  and  detachment  of  the 
dead  segment  is  a  most  tedious  process,  and,  for  final  completion, 
one  may  reckon  on  a  period  lasting  from  one  and  a  half  to  two 
years. 

Prognosis. — Maxillary  necrosis  does  not  endanger  the  patient's 
life;  yet  it  may  be  reckoned  as  a  most  serious  annoyance,  since 
the  function  of  the  jaw  is  seriously  impaired.  The  condition  in 
wliich  the  pus  has  escaped  through  an  external  opening,  is  a 
more  fortunate  one  than  that  in  which  the  purulent  material  and 
osseo.us  detritus  enter  the  oral  cavity,  and  are  swallowed,  or, 
what  is  yet  more  deleterious,  some  of  this  material  descends  into 
the  lungs  and  affects  the  pulmonary  tissue;  in  the  latter  case, 
life  is  so  seriously  compromised  that  death  has  occurred;  and  in 
the  other  case,  the  matter,  being  swallowed  and  absorbed,  impairs 
general  nutrition. 

Treatment. — The  treatment  consists  in  maintaining  a  conven- 
ient outlet  for  the  purulent  matter  until  the  dead  structure  has 
become  detached  from  the  living  bone;  and  finally,  the  necrosed 
bone  must  be  removed. 

As  soon  as  there  is  evidence  of  the  existence  of  pus,  one  or 
more  openings  must  be  made  through  which  the  purulent  material 
can  have  ready  escape;  and  such  opening  should,  if  possible,  be 
through  the  soft  structures  near  the  lower  border  of  the  jaw.  If 
the  decaying  bone  be  of  large  dimensions,  such  orifice  of  escape 
must  be  kept  patent  until  the  dead  bone  is  loose  within  the 
ensheathing  new  structure. 

When  the  sequestrum  has  become  loose  within  its  envelope 
of  new  bone,  it  should  be  extracted;  and  for  this  work  there  are 
two  routes,  viz.,  external  and  intra-oral.  If  the  destructive 
process  be  limited  to  the  alveolar  portion  of  the  jaw,  the  seques- 
trum can  be  reached  and  extracted  through  the  mouth;  but  if 
the  lower  border  be  the  affected  part,  then  it  is  better  to  remove  it 
from  the  outside,  and  this  can  best  be  done  by  enlarging  a  fistu- 


/42  MAXILLA    INFKHIOR. 

lous  0])cning,  if  such  exist.  Wliere  the  horizontal  portion  is 
extensively  necrosed,  and  listukc  exist  tlirouuli  wliicli  the  puru- 
lent detritus  escai)es,  an  incision  connecting  two  or  more  of 
these  oi^enings  should  be  made,  and  then  through  tlie  incisir)n 
the  bone  can  be  examined  and  the  dead  j^ortion  removed  tiirougli 
an  orifice  in  the  new  bone;  and  if  this  orifice  be  too  small,  it  may 
be  enlarged  to  the  necessary  extent.  In  case  the  sequestrum 
be  long  and  conoidal  in  sha})e,  then  it  should  be  extracted  by  its 
base  rather  than  by  its  smaller  end,  for  if  the  attempt  be  made 
to  extract  the  reverse  of  this,  the  sequestrum  will  become  wedged 
in  the  conical  canal  and  immovably  fastened  there.  The  experi- 
ence of  the  writer  furnishes  this  suggestion. 

The  work  of  extraction  may  often  be  facilitated  by  dividing 
the  sequestrum  at  its  middle,  and  then  removing  each  fragment 
se})arately.  Such  division  can  be  done  with  a  pair  of  small- 
bladed  cutting  forceps. 

During  the  preliminary  sequestration  of  the  dead  bone,  as 
well  as  after  it  has  been  removed,  tlie  buccal  cavity  should  be 
rinsed  out  with  mint-water,  tar-water,  cidorinated  water,  al(;o- 
holized  water,  camphor  Avater  or  other  detersive  antise})tic 
solution. 

The  fistuhe  which  accompany  maxillary  necrosis,  and  open 
intra-orally  or  extra-orally,  will  soon  heal  after  removal  of  the 
sequestrum;  and  this  closure  will  be  accelerated  if  the  granula- 
tive  tissue  which  lines  the  canal  be  removed;  and  this  may  be 
done  with  scissors  and  curette. 

If  this  work  be  done  prior  to  the  appearance  of  the  second 
teeth,  there  is  danger  of  destroying  the  germs  of  the  latter,  unless 
the  j)ortions  of  the  alveolar  process  containing  these  germs  can 
be  left  intact;  and,  as  far  as  it  is  possible,  the  o[)erator  should  spare 
these  portions.  Besides  this,  it  is  equally  important  that  tlie 
necrosed  bone  should  not  be  removed  until  the  whole  of  it  can  be 
extracted;  and  this  time  is  usually  cotemporaneous  with  the 
development  and  completed  formation  of  the  new  bone,  which 
replaces  the  original  maxillary  structure. 

In  case  of  a  considerable  portion  of  the  inferior  maxilla  being 
lost,  the  replacing  material,  even  when  toothless,  has  enabled  the 
patient  to  masticate  food  which  was  not  very  hard;  and  if  its 
use  in  this  respect  is  unsatisfactory  to  the  patient,  he  is  at  least 
in  a  condition  to  wear  an  artificial  set  of  teeth,  since  such  pro- 
thetic  substitute  is  more  readily  maintained  in  position  on  the 
lower  than  on  the  upper  jaw. 


PHOSPHOEUS-XECROSIS.  743 

Phosphorus- Necrosis.— The  industrial  occupations  of  civilized 
man  have  widened  the  bounds  of  surgical  pathology  and  surgi- 
cal practice;  and  this  applies  to  those  who  manufacture  the 
lucifer  match,  for  to  this  occupation,  as  causal  agency,  is  referred 
a  form  of  maxillary  necrosis.  As  this  industry  has  flourished, 
especially  on  German  soil,  one  finds  that  the  first  study  of  the 
subject  was  made  in  Germany:  to  the  pen  of  Lorinser,  of  Vienna, 
and  afterwards  to  Heyfelder  are  due  the  original  descriptions  of 
the  disease.  The  observation  was  early  made  that  necrosis  of  the 
jaws  often  occurred  among  the  laborers  of  the  match  factory. 

Lorinser,  pioneer  in  th'e  study  of  the  subject,  claimed  that  the 
disease  was  due  to  the  inhalation  of  fumes  of  phosphorus.  This 
was  contested  by  others,  who  urge  that  the  maxillary  disease  is 
due  to  exposure  of  the  laborer  to  currents  of  cold  air.  Others 
again  claim  that  the  subjects  of  such  necrosis  were  already  labor- 
ing under  affection  of  the  teeth,  the  gums  or  the  alveolar  process, 
and  that  witliout  exposure  to  fumes  of  phosphorus  these  same 
persons  would  have  developed  necrosis. 

But,  despite  the  opinion  of  a  few  dissenters,  who,  here  as  else- 
where, seek  to  ply  their  barks  against  the  current  of  common 
opinion  until  the  force  of  that  current  overwhelms  them,  general 
observation  agrees  that  phosphorus  is  the  cause  of  the  maxil- 
lary disease,  and  in  its  action  there  is  an  analogy  with  that  of 
mercury.  As  is  known,  mercury  introduced  into  tlie  organism 
in  large  amount  finally  induces  salivation  and  inflammation  of 
the  gingival  tissues,  and  the  alveolar  processes ;  in  some  way 
cognate  to  mercurial  action,  phosphorus  exercises  its  destructive 
action  on  the  dental  and  alveolar  structure;  yet  in  what  form  the 
metalloid  acts,  whether  as  an  acid,  a  salt,  or  as  pure  phosphorus, 
remains  for  determination  by  the  pathological  chemist.  Decayed 
teeth  and  a  diseased  condition  of  the  soft  parts  around  the  teeth 
seem  to  prepare  the  way  for  the  action  of  the  phosphorus;  and  if 
these  conditions  are  absent,  the  disease  does  not  appear.  That  it 
is  not  frequent  among  laborers  who  are  exposed  to  phosphorus  is 
shown  by  the  observation  of  Meyer,  that  among  twelve  hundred 
laborers  during  a  period  of  thirteen  years,  there  occurred  but 
three  cases  of  maxillary  necrosis.  The  disease  attacks  both  the 
upper  and  the  lower  jaws ;  yet  is  much  oftener  seen  in  the  inferior 
one,  since  the  position  of  the  latter  favors  the  lodgment  and  action 
of  morbific  agents.  Von  Bibra  and  Geist  have  instituted  experi- 
ment on  rabbits  in  which  the  animals  were  exposed  to  the  fumes 
of  phosphorus;  and  the}'' found  that  the  animals  were  not  affected 


744  MAXii.i.A  infi:ki()K. 

unless  their  teeth  and  jaws  had  previously  been  subjected  to 
some  injury. 

The  disease  commences  as  an  alveolo-dental  inflammation; 
the  gingival  tissues  are  swollen  and  spongy,  and  suppuration 
occurs  around  tlie  teeth;  and  at  this  stage,  siiould  the  laborer 
cease  his  occu|)ation,  tlie  disease  is  arrested;  and  thougli  the 
teeth  loosen  and  drop  out,  yet  necrosis  does  not  occur  in  the  jaw; 
but  if  the  exposure  is  continued,  sub-periosteal  abscesses  develop), 
and  the  maxillary  body  is  next  attacked  and  dies  in  continuity, 
or  in  different  sections.  These  abscesses  rupturing  into  the 
mouth,  leave  ulcer-like  fistulous  openiiigs.  The  teeth  fall  from 
the  affected  part,  the  subjacent  bone  dies,  and  new  bone,  in  regu- 
lar or  irregular  outline,  is  developed  around  tlie  central  seques- 
trum. 

Meantime  the  jaw  is  swollen  and  there  may  be  tumefaction  of 
the  adjacent  soft  parts;  and  the  pus  thence  resulting  may  jDerfo- 
rate  the  containing  wall,  and  appear  externally.  Pain  in  the 
teeth  is  the  initial  symptom,  and  this  may  be  fixed  in  one  point, 
or  it  may  shift  erratically  and  be  felt  in  the  ear,  temple,  or  even 
in  the  shoulder.  The  pain  may  be  bilateral  and  sliglit,  or  it  may 
be  intense  and  concentrated  in  one  point  of  the  face,  similar  to 
neuralgia.  When  pus  has  formed  and  a  free  discharge  estab- 
lished, the  pain  lessens  and  may  qiuie  vanish. 

As  the  disease  progresses,  the  new  osseous  production,  desig- 
nated osteophytic,  presents  itself  in  two  forms.  The  one  which 
is  denominated  phosphoric  osteophyte,  remains  fastened  to  the 
dead  bone  and  the  surface  of  the  latter;  and  this  consists  of  fine 
lamelltB  which  intercross  and  are  mingled  in  an  irregular  man- 
ner; and  these,  in  mass,  resemble  the  structure  of  spongy 
platinum,  or  pumice  stone.  In  the  other  kind  of  production, 
the  new  o.sseous  growth,  in  stratified  layers,  is  adherent  to  the 
periosteum,  and  this  may  be  eburnated,  or  of  spongy  texture. 
The  so-called  phosphoric  osteoj^hyte  occupies  the  deeper  portions 
of  the  new  osseous  production;  while  that  of  lamellated  structure, 
and  which  is  of  periosteal  origin,  is  situated  more  externally. 
hi  this  abnormal  osteogony  the  process  of  rarefaction  exceeds 
that  of  eburnation  or  condensation.  And  each  of  these  condi- 
tions is  favorable  to,  or  permits  death  or  regressive  action  in  the 
new-formed  bone;  in  the  dense  form  there  may  die  isolated  tracts 
through  insufficient  blood  su})ply;  and  in  the  rarefied  species  the 
enlarged  vessels  which  traverse  it  may  cause  absorption.  Tliis 
new  os.seous  growth,  examined  chemically  and  microscopically, 
conforms  to  the  structure  of  new  bone  arising  elsewhere. 


PHOSPHORUS-NECROSIS.  745 

The  sequestrum  formed  has  an  irregular  surface ;  it  is  porous 
and  of  a  dirty  grajdsh  color;  and,  in  its  porous  structure,  it  resem- 
bles somewhat  the  new  growth  of  bone  which  is  developed  around 
it;  and  again,  at  another  point,  the  dead  bone  may  be  dense  and 
ivorj^-like.  The  process  of  inflammation,  suppuration,  destruc- 
tion and  repair  of  the  maxillary  structures  differs  but  little  from 
the  same  process  which  attends  necrosis  arising  from  other  causes ; 
if  that  from  phosphorus  has  any  special  characteristic,  it  is  its 
obstinate  persistence. 

The  necrosed  maxillary  structure  tends  usually  to  make  its 
exit  by  way  of  the  mouth;  the  way  is  opened  and  remains  so,  in 
this  direction,  in  consec[uence  of  the  slight  reproduction  of  bone 
which  occurs  here;  this  applies  to  the  alveolar  processes  of  the 
upper  and  lower  jaw:  but  in  the  body  of  the  lower  one,  the 
sequestrum  is  so  inclosed  by  the  new  structure,  that  usually 
surgical  aid  is  needed  to  permit  its  escape. 

Besides  the  upper  and  lower  jaws,  the  proximal  facial  bones 
may  become  implicated  in  the  necrosis;  this  action  is  not  pri- 
mary, but  is  consecutive  to  tliat  beginning  in  the  maxillae. 
Such  secondary  invasion  has  been  seen  in  the  malar,  palatal  and 
the  turbinated  bones;  also  in  the  vomer  and  the  ethmoid;  and 
sometimes,  by  remote  propagation,  the  disease  has  attacked  the 
frontal,  the  temporal,  the  sphenoid,  and  even  the  occipital  bones. 

The  manner  in  which  the  new  bone  is  produced  is  similar  to 
that  occurring  in  maxillary  necrosis  from  other  causes.  Such 
restoration  is  never  complete  and  tl^e  reproduction  takes  place 
much  oftener  in  tlie  lower  than  in  the  upper  jaw.  The  incom- 
pleteness of  the  new  structure  is  partly  due  to  abnormal  develop- 
ment; and  also  to  the  fact  that  the  new-formed  bone  is  usually 
liable  to  be  lessened  by  subsequent  absorption  of  some  of  the  new- 
formed  layers  of  bone.  According  to  Salter,  tlie  regeneration  of 
the  inferior  maxilla,  even  in  the  best  form  which  such  regrowth 
presents,  is  very  far  from  normal  maxillary  type;  and  even 
though  the  arch  be  fairly  restored,  after  some  years,  the  bone 
becomes  greatly  reduced  in  size.  Such  atrophic  process  may 
continue  eight  or  ten  years.  Osseous  reproduction  has  rarely 
been  seen  in  case  of  phosphorus-necrosis  of  the  upper  jaw. 

Visceral  complication  concurrent  with  phosphorus-necrosis 
has  been  observed  in  a  few  cases.  Haltenhoff  reports  amyloid 
degeneration  of  the  liver,  spleen  and  kidneys;  also  renal  inflam- 
mation has  been  seen.  Bucquoy  reports  the  autopsy  of  a  woman 
who  died  from  phosphorus-necrosis,  in  which  the  manifestations  of 
48 


74*3  MAX  1 1. 1.  A    INFKIUOR. 

general  poisoning  from  phosphorus  were  ])resent,  viz.,  falty  degen- 
eration of  tiie  heart,  liver,  kidneys  and  the  muscles.  Inasmuch 
as  fow  die  from  phosphorus-necrosis,  there  have  been  but  few 
opportunites  for  tiie  determination  of  visceral  complication;  such 
complication  is  probably  rare,  else  indications  of  it  would  show 
themselves  in  the  living  patient. 

Wlien  the  subjective  phenomena  are  .studied,  the  patients 
may  be  divided  into  two  groups.  In  one  elas.s,  described  by 
Lailler,  the  patient's  general  health  is  so  little  impaired  that  he 
does  not  discontinue  his  occu[»ation;  he  remains  at  his  work, 
thinking  but  little  of  his  ailment  until  the  sequestrum  loosens, 
and,  perhaps,  escapes  into  his  mouth;  especially  if  the  disease 
be  in  the  upper  jaw.  And  in  others,  the. patient  is  so  little 
disturbed  by  his  affection,  that  he  does  not  seek  surgical  aid 
until  the  disease  is  well  advanced;  the  bone  is  dead  and  fistulic 
open  to  it.  In  another  class,  the  disease  is  more  severe;  there  is 
extensive  swelling,  with  violent  pain  and  general  fever.  AViieii 
suppuration  occur.s,  the  patients  become  j^ale,  feeble  and  ema- 
ciated; albumen  appears  in  the  urine;  and  the  vital  forces  being 
consumed,  death,  after  a  long  period,  occurs  from  exhaustion. 

The  prognosis  is  inore  unfavorable  than  in  any  other  form  of 
maxillary  necrosis.  According  to  Trelat,  when  both  upper  and 
lower  jaws  are  the  site  of  phosphorus-necrosis,  one-half  of  the 
cases  die;  if  the  upper  jaw  only  is  affected,  one-third  of  the 
cases  die;  but  if  the  lower  jaw  is  the  seat,  one-fourth  of  tlie 
patients  die.  At  Ziirich,  Billroth  observed  four  deatlisin  twenty- 
four  cases.  Yet  in  the  history  of  the  fatal  cases,  death  generally 
resulted  from  sotae  accidental  complication ;  so  that  it  may  be 
concluded  that  tho.se  who  are  otherwise  in  ro])ust  health,  rarely 
die  from  phosphorus-necrosis. 

Treatment. — The  jiatient  should,  at  once,  be  removed  from  the 
causal  agency  of  his  disease;  he  must  abandon  his  occupation  in 
the  match  manufactory. 

Internal  medication  has  been  advised,  and  benefit  from  tlie 
use  of  iodide  of  potassium  has  been  claimed.  The  excreta  from 
the  necrosing  bone  should  be  removed  from  the  buccal  cavity 
through  irrigation  with  alcoliolized  water,  mint-water,  dilute 
claret  wine;  or  a  weak  solution  of  borax  or  chlorate  of  pot:i.sh 
may  be  used.  As  mastication  is  trammeled  by  the  affected  teeth, 
care  must  be  taken  that  tlie  patient  shall  have  an  ample  nourisli- 
ment  from  semi-liquid  food. 

In  respect  to  the  management  of  tlie   necrosing  bone,  two 


PHOSPHORUS-XECROSIS.  747 

plaDs  of  treatment,  opposite  in  character,  have  their  emulous 
advocates;  in  one,  the  practice  is  to  extirpate  the  dead  bone  at 
an  early  period;  in  the  other,  the  removal  is  deferred  to  a  late 
jDeriod. 

Early  intervention  is  advocated  by  Billroth,  who  counsels,  in 
cases  in  which  the  disease  threatens  to  run  a  course  of  a  year  or 
more,  to  intervene  long  before  there  is  a  furrow  of  separation 
between  the  dead  and  the  living  bone,  and  to  remove  the  diseased 
part;  for,  thus  doing,  one  diminishes  or  arrests  the  suppurative 
stream  at  its  source,  and  its  exhausting  consequences  are  averted. 
It  is  true  that  such  early  interference  is  not  followed  by  a  com- 
plete cure;  two  or  three  subsequent  operations  may,  perhaps,  be 
necessary.  The  subsequent  necrosis  which  occurs,  is  not  to  be 
referred  to  the  operation;  it  is  merely  the  natural  course  of  the 
disease;  and  the  disposal  of  the  bone  which  is  already  dead 
places  the  patient  in  a  better  condition  to  endure  that  which  fol- 
lows. The  section  of  the  dead  from  the  living  bone,  Billroth 
thinks,  enables  the  latter  to  better  resist  the  process  of  necrosis. 
In  the  single  case  in  which  the  disease  is  limited  to  the  surface 
of  the  alveolar  process,  he  would  wait  for  the  bone  to  become 
loose,  before  extracting  it. 

Another  ground,  on  which  an  early  removal  is  advocated,  is 
that,  thus  doing,  the  conditions  are  favored  for  new  osseous  pro- 
duction; for  the  prolonged  presence  of  the  necrosed  bone  pro- 
motes absorptive  action  of  the  newly-regenerated  structure;  in 
fact,  the  new  bone  has  sometimes  nearly  vanished  from  this 
cause. 

Hence  those  who  counsel  early  intervention  would  operate  at 
the  end  of  six  or  eight  months;  at  that  time  the  dead  and  living- 
bone  can  be  distinguished  from  each  other. 

Lorinser  advises  to  interfere  at  a  late  period:  and  this  practice 
is  also  followed  by  Trelat.  Lorinser  would  only  operate  at  an 
early  period  on  those  patients  in  which  the  pain  is  excessive,  or 
the  suppuration  is  exhausting  the  strength.  As  principles  which 
should  serve  for  guidance  in  operative  work,  Trelat  has  formu- 
lated tlie  following:  as  long  as  the  sequestrum  remains  immov- 
able, one  should  not  attempt  its  extraction;  one  should  never 
attack  with  the  resecting  instruments  parts  which  are  sound; 
but  when  the  dead  part  is  movable,  then,  by  division  of  the  soft 
parts  and  section  of  the  bone,  the  sec[uestrum  may  be  removed. 
In  operating  early,  Trelat  urges  that  tlie  surgeon  runs  the  risk  of 
doing  too  little,  or  too  much  :  serms  of  the  disease  are  left  behind. 


748  MAXILLA    IXFERIOR. 

whence  the  iiiHammation  is  rehghted;  and  the  atlectiou  return- 
ing, may  destroy  life  by  exhaustion. 

Hence,  as  appears,  the  surgeon  has  authority  to  justify  either 
early  or  tardy  intervention:  tiie  writer  espouses  the  former  plan, 
and,  as  advised  first  l)y  Billroth,  and  afterwards  by  ^h^isonneuve 
and  Verneuil,  he  would  attack  the  disease  in  the  beginning;  and, 
by  thus  doing,  hope  to  stay  its  progress. 

The  operation  of  sequestrotomy  for  tiio  relief  of  phosphorus- 
necrosis  consists  of  three  acts:  detachment  of  the  })eriosteum,  sec- 
tion of  the  bone,  and  extraction  of  the  dead  bone;  and  to  aid  in 
the  removal,  it  may  be  necessary  to  divide  the  sequestrum  into 
two  or  more  parts.  If  the  dead  bone  be  of  small  size,  the  work 
may  be  done  through  the  mouth;  but  if  the  sequestrum  be  of 
much  magnitude,  an  external  incision  should  be  made,  through 
which  the  removal  can  be  done;  and  when  thus  done,  it  should 
be  a  cardinal  rule  to  avoid,  as  far  as  possible,  entrance  into  the 
buccal  cavity;  and  this  is  best  done  by  keeping  the  chisel  or 
blunt  dissector  in  contact  with  the  bone,  in  separating  the  soft 
parts  from  the  maxilla.  After  the  diseased  osseous  structure  has 
been  removed,  the  remaining  wound  should  be  sim})ly  treated 
in  accordance  with  rules  already  given  for  the  management  of 
operative  work  within  the  oral  cavity;  the  chief  thing  to  be  done 
is  to  frequently  cleanse  tlie  cavity,  and  thus  avoid  the  swallow- 
ing of  septic  matters. 

GrowtJis  in  the  Maxilla  Inferior. — Maxillary  tumors  may  be 
classified  as  benign,  semi-malignant  and  malignant.  Within 
the  first  class  may  be  included  the  dental  cystoma,  odontoma  and 
fibroma;  in  the  second,  epulis;  and  in  the  third,  sarcoma,  epi- 
thelioma and  carcinoma.  Of  the  benign  and  semi-malignant 
classes  a  somewhat  extended  description  will  be  given ;  but  the 
third  class  will  be  noticed  more  briefly. 

JIaxillo- Dental  Cystic  Tumors. — Guibourt,  in  1845,  inade  a  study 
of  cystic  growths  which  develop  within  the  maxillary  bones.  He 
finds  that  such  growths  have  been  seen  by  Petit,  Cooper  and 
Hawkins,  yet  tiie  nature  of  the  tumors  was  imperfectly  undt-r- 
stood  by  these  surgeons.  The  subject  was  afterwards  the  matter 
of  research  by  Dupuvtren  and  X^laton,  who  partially  solved  the 
proVjlem  of  the  nature  and  mode  of  origin  of  the  maxillary  cyst. 

As  a  compendious  history  of  such  tumor  Guibourt  gives  the 
following:  the  growth  commences  as  a  slightly  painful  and  slowly 
developing  tumor  in  the  maxillary  region,  which  finallv  crepitates 
an<l  fluctuates  when  ^n-essed  on;  and  when  it  attains  some  magni- 


MAXILLO-DENTAL    CYSTIC    TUMORS.  749 

tude,  the  teeth  fall  out,  and  the  overl3'ing  bone  disappears  by 
absorption. 

According  to  Nelaton  it  can  arise  in  one  of  three  wars:  (1)  a 
morbid  condition  of  the  dental  vesicle,  wlience  arise  hypertrophy 
and  an  excessive  secretion  of  liquid  or  semi-liquid  material, 
which  usually  arrests  the  development  of  the  tooth;  or  the  tooth 
may  develop  in  the  cyst.  (2)  From  mal-position  of  the  tooth,  the 
latter  crowds  on  the  adjacent  bone,  and  creates  a  cavity  in  which 
fluid  is  secreted  from  the  dental  capsule.  (3)  From  the  unusual 
vital  activities  of  the  maxillary  bones,  conditions  are  present  which 
favor  such  development. 

In  1873,  Magitot  wrote  an  exhaustive  monograph  on  maxil- 
lary cysts,  from  which,  as  well  as  from  the  writings  of  Broca,  the 
writer  has  derived  many  of  the  facts  which  hereafter  follow. 

Every  maxillary  cyst  is  either  of  dental  or  -periosteal  origin. 
It  appears  normally  in  any  portion  of  the  alveolar  process,  from 
the  symphysis  in  front,  to  the  last  molar  tooth  behind,  and 
in  such  situation  it  occupies  the  position  normally  filled  by 
one  or  more  teeth.  Yet,  exceptionally,  the  cyst  may  be  situated 
abnormally,  viz.:  it  may  appear  in  the  nasal  process  of  the 
upper  jaw,  in  the  orbital  portion  of  the  same,  in  the  canine 
fossa,  finally,  in  the  ramus  of  the  lower  jaw.  And  these,  like 
those  appearing  in  the  alveolar  process,  are  follicular  in  char- 
acter, and  have  arisen  from  the  displacement  of  dental  follicles. 

These  cysts  may  seem  to  have  a  compound  character,  which, 
however,  is  not  really  so,  for  the  compound  or  divided  form  has 
arisen  from  the  diseased  dental  follicle  having  encountered  some 
hindrance,  such  as  an  inter-dental  septum;  or  it  may  arise  from 
two  or  more  follicles  having  united  or  pressed  together. 

The  cyst  may  vary  in  volume  from  the  size  of  a  pea  to  a  much 
larger  volume.  In  its  development  it  may  grow  into  the  mouth; 
or  it  can  expand,  and,  encroaching  on  the  parts  around  it,  it  may 
push  these  aside.  The  mucous  membrane  which  covers  it,  be- 
comes vascular  and  injected  with  blood;  but  should  it  grow 
towards  the  skin,  the  latter  remains  unchanged. 

When  the  cyst  is  of  periosteal  origin,  in  developing,  it  may 
awaken  an  inflammatory  action  which  finally  ends  in  suppuration; 
and  through  suppurative  action  the  cyst  may  open,  and  discharge 
its  contents,  and  afterwards  fill  again.  Or,  if  there  be  growth 
without  inflammation,  the  cyst  may  continue  to  enlarge  until  its 
osseous  structure  is  absorbed,  and  the  remaining  wall  consists  only 
of  mucous  membrane.    This  thin  wall  may  be  invested  with  villi, 


iOU  MAX  1  LI. A     INFKIilOK. 

or  it  may  be  smooth,  shining  and  transparent.  It  is  not  always 
adherent  to  the  adjaeent  pans.  The  structure  of  this  -wall  is  sim- 
ihir  to  that  of  the  dental  follicle,  and  contiguous  periosteum. 

In  cysts  of  both  follicular  and  periosteal  origin,  the  content  is 
thin,  clear,  serous,  or  mucous  in  cliaracter  in  those  cases  in  wliich 
the  development  has  been  slow;  but  if  the  growtli  has  been  rapid, 
the  content  may  be  discolored.  Besides  those  with  the  liquid 
content  mentioned,  cysts  also  occur  of  which  the  content  may  be 
bloody,  purulent  or  fat-like. 

According  to  the  time  of  origin,  Broea  classifies  these  cysts 
into  those  of  the  embryoplastic  period,  tlie  odontoplastic  period, 
and  tlie  coronary  period. 

The  embryoplastic  class  corresponds  to  that  period  in  the 
evolution  of  the  tooth,  in  wdiich  the  germ  is  contained  in  a  sack 
or  follicle;  such -cysts  have  liquid  content  in  which  there  may  be 
sebaceous  matter.  The  odontoplastic  class  arises  at  the  time  when 
bony  matter,  or  ivory,  is  being  formed  on  tlie  developing  tooth: 
and  such  cysts  present  a  liquid  content  in  whicli  are  osseous 
masses.  Tlie  cysts  of  the  coronary  period  correspond  in  date  to 
a  later  period  in  the  evolution  of  the  tooth;  in  such  cy.st  is  found 
the  crown  of  a  tooth,  or  an  entire  tooth.  The  last  class  is  the 
most  numerous. 

When  there  is  a  dental  cyst,  as  a  rule,  there  is  the  absence  of 
one  or  more  teeth ;  yet  this  is  not  always  so,  for  all  the  teeth  may 
be  present,  and  then  such  cyst  is  referable  to  a  supernumerary 
dental  follicle. 

From  the  observation  of  one  hundred  ca.ses,  Magitot  concludes 
that  when  it  is  congenital  the  cyst  may  remain  undeveloped  for 
some  years.  From  birth  until  twenty-nine  years  of  age,  the  fol- 
licular form  is  the  more  frequent;  but  after  that  time,  the  perios- 
teal form  is  the  more  common  one:  to  be  explained,  proljably,  on 
the  ground  that  in  infancy  and  early  life  the  follicular  dental 
germ  is  in  a  state  of  high  activity,  while  later,  the  dental  perios- 
teum is  the  frequent  subject  of  morbific  action  from  the  adjacent 
teeth.  The  origin  of  the  follicular  form  is  a  matter  of  conjecture ; 
while  the  periosteal  species  is  referable  to  some  agency  which 
awakens  a  periosteal  inflammation.  In  the  follicular  form,  rem- 
nants of  teeth  are  found;  numbers  varying  from  two  to  twenty 
dental  crowns  have  been  seen;  and  from  this  circumstance  this 
species  has  been  named  dental  coronal  cyst. 

In  the  periosteal  s|)ecies  the  mode  of  development  is,  that  the 
periosteum  becomes  uplifted  from  the  cenientum,  especially  from 


MAXILLO-DENTAL    CYSTIC    TUMORS.     '  751 

the  end  of  the  dental  root;  and  followino-  the  periosteal  detach- 
ment there  is  poured  into  the  opened  space  a  small  quantity  of 
fluid;  and  this  is  retained,  since  there  is  no  outlet  for  its  escape. 
The  effused  material  augments,  and  finally  causes  decay  in  the 
root  of  the  tooth;  and  this  tooth  becomes  imperfect;  and  others 
adjacent  may  become  implicated,  and  also  deca3\  If  the  tooth  is 
full-formed,  then  its  displacement  causes  dragging  on  the  nerve 
that  is  supplied  to  it;  and  thus  pain  arises.  Later  the  nerve 
dies,  and  the  pulp  in  the  root  of  the  tooth,  likewise,  decays;  and 
the  affected  tooth  then  has  a  gray,  dark  or  bluish  appearance. 
The  cyst  thus  formed  can  develop  laterally;  and  encroaching  on 
tlie  adjoining  tooth,  this  may  be  uprooted;  or  the  cyst  may  form 
around  it. 

In  regard  to  pain,  the  follicular  dental  cyst  in  its  first  stage, 
is  painless;  but,  at  a  later  period,  when  nerves  are  encroached 
upon,  it  is  painful.  But  the  periosteal  cyst  is  painful  in  the 
beginning,  so  that  the  patient  desires  the  removal  of  the  tooth; 
and  such  tooth  being  early  extracted,  a  small  cyst  will  be  found 
in  the  root.  If  the  tooth  is  not  removed,  the  cyst  will  continue 
to  grow,  until  finally  it  attains  large  dimensions ;  and  its  walls 
may  then  be  so  thin,  that  they  yield  under  pressure,  giving  the 
crackling  sensation  of  parchment.  The  large  follicular  cyst  is 
also  compressible;  but  such  attenuation  of  "wall  is  only  attained 
after  many  years  of  growth.  In  the  periosteal  species,  if  the 
affected  tooth  be  extracted  at  an  early  jieriod,  further  develop- 
ment may  sometimes  be  prevented;  sometimes,  however,  the 
opening  in  the  alveolar  process  may  close  up,  and  the  cyst  con- 
tinue its  growth. 

The  maxillary  cyst,  through  suppurative  action  may  open; 
also,  when  the  content  is  of  serous  character,  it  may  rupture  and 
discharge;  and  when  an  opening  thus  occurs,  the  breach  may 
close,  and  remain  so  for  a  time. 

The  maxillary  cyst  may  pulsate,  and  thus  simulate  an  aneurys- 
mal tumor;  such  pulsatile  action  is  due  to  vessels  in  the  wall  of 
the  tumor.  Doubt  as  to  the  nature  of  the  case  would  be  cleared 
up  by  the  use  of  an  exploring  needle. 

Solid  tumors,  whether  of  osseous  or  other  tissue,  within  tlie 
lower  jaw,  thrust  the  adjacent  bone  in  every  direction;  but  if  the 
tumor  be  cystic,  it  extends  more  towards  the  face,,  that  is,  out- 
wards. Should  a  tooth  be  absent  in  a  young  subject,  this  indi- 
cates a  cyst  of  dental  origin.  A  multilocular  maxillary  cyst,  the 
origin  of  which  is  not  traceable  to  either  dental  follicle  or  to 


,.yl  MAXILLA    IXFKKIOll. 

dental  periosteum,  lias  been  observed.  Its  occunenee  is  exceed- 
ingly rare.  This  tumor  presents  an  irregular  surface,  being  ])ro- 
tuberant  or  embossed  at  points;  and  a  protruded  ])ortion  may  be 
bounded  by  a  wall  so  thin  that  it  crepitates  wlien  pressed  upon. 
This  non-dental  cyst  has  sometimes  developed  very  rapidly;  in 
other  cases,  the  growtli  was  of  long  dui-ation. 

Treatment  of  ihe  Maxillary  Denial  Cyst. — The  cyst  of  periosteal 
dental  origin,  sliould  be  treated  by  removal  of  the  tooth  or  teeth 
which  are  affected;  and  should  the  extraction  be  done  before  the 
disease  has  progressed  far,  then  an  immediate  closure  of  the  part 
may  be  reached,  and  an  early  cure  obtained.  Should,  however, 
the  disease  have  progressed  so  far  as  that  a  large  cavity  is  formed, 
then  the  process  of  rejjair  will  be  tedious,  and  the  treatment  will 
reach  through  a  period  of  many  months.  In  the  species  origi- 
nating from  the  dental  follicle,  the  volumereached  in  development 
is  commonly  greater  than  that  from  periosteal  origin;  and 
consequently,  though  the  case  is  always  curable,  yet,  from  the 
writer's  experience,  to  effect  this,  patient  and  continued  effort  is 
demanded.  In  two  cases  treated  by  him,  the  disease  had  evi- 
dently originated  in  the  embryoplastic  period.  The-operation 
done  was  to  open  the  cavity,  excise  a  portion  of  the  parchment- 
like wall,  and  to  remove  the  contents;  and  then  the  inner  surface 
of  the  cystic  wall  was  carefully  curetted.  The  cavity  which 
remained  was  then  filled  with  lint  saturated  with  alcoholized 
water.  In  this  manner  the  wound  was  daily  redressed,  and  after 
protracted  attention,  the  cases  were  cured.  The  writer's  experi- 
ence has  taught  him  that  the  most  important  part  of  such  oper- 
ation is  to  remove  all  that  is  possible  of  tlie  outer  wall  of  the  cyst ; 
thus  done,  the  cavity  is  secured  against  premature  closure,  and  a 
final  cure  is  insured.  AVhere  the  cyst  has  a  favorable  conforma- 
tion, and  is  easily  accessible,  it  might  be  possible  to  remove  the 
outer  osseous  wall,  and  so  retain  its  mnco-periosteal  investment, 
that  this  could  be  made  to  cover  the  remaining  wall;  and  thus  a 
speedy  care  be  obtained;  yet  tlie  writer's  experience  justifies  the 
prediction  that  the  attempt  here  indicated  would  usually  fail,  and 
the  wound  then  heal  by  granulation  and  cicatrization. 

Odontoma. — The  odontoma  is  a  solid  tumor  which  has  an 
indirect  relationship  to  the  teeth;  it  is  composed  of  elements  cog- 
nate to  those  of  dental  structure;  and  was  formerly  named  a 
dental  exostosis.  Our  present  knowledge  of  this  growth  is  chiefly 
due  to  the  researches  of  Broca. 

Broca  finds  that  the  odontoma  originates  from  a  hypertrophy 


ODONTOMA.  753 

of  the  dental  pulp;  remaining  for  a  time  in  a  soft  state, 
this  afterwards  ossifies,  or  dentifies,  as  Broca  styles  it.  There 
primarily  occurs  a  hypergenesis  or  multiplication  of  the  inceptive 
dental  elements;  and  this  structure,  when  it  has  passed  througli  a 
soft  and  vascular  stage,  next  becomes  the  site  of  osseous  or  dental 
deposits,  either  within  the  tumor,  or  on  its  outside.  When  the 
growth  is  in  its  soft  stage,  it  is  named  the  non-dentified  odon- 
toma; but  after  ossification,  it  is  named  dentified  odontoma;  in 
the  former,  the  soft  structure  is  homogeneous  in  composition ;  but 
in  assuming  the  dentified  form,  the  primitive  material  is  differ- 
entiated, and  forms,  remotely  resembling  teeth,  are  developed  in 
it.  These  odontoid  structures  may  be  separable,  or  tliey  may  be 
crowded  together  into  a  shapeless  mass. 

.  The  hypertrophic  action  may  take  place  near  the  crown;  and 
this  form  is  named  the  coronary  odontoma;  and  here,  at  the  base 
of  the  crown,  there  occurs  a  lateral  exostosis  composed  of  dental 
ivory  and  enamel.  Or  the  hypertrophy  may  proceed  from  the 
radical  portion  of  the  tooth:  a  form  named  radical  odontoma. 
The  radical  odontoma  can  encroach  on  and  imprison  the  roots  of 
adjacent  teeth. 

The  era  of  the  development  of  the  odontoma  is  during  the 
period  of  second  dentition;  it  is  most  common  in  the  molar 
region;  the  coronary  odontoma,  however,  occurs  only  in  the  region 
of  the  incisor  teeth. 

During  development  the  odontoma  causes  pain  of  a  neuralgic 
character.  Its  appearance  is  announced  by  swelling  and  pain, 
constant  or  recurrent;  and  later,  an  abscess  forms,  and  bursting 
leaves  fistulous  openings. 

It  is  often  difiicult  to  distinguish  between  the  dental  cyst  and 
the  odontoma;  and  to  do  so,  an  exploratory  incision  may  be 
necessary;  then,  if  the  case  is  cystic,  one  enters  a  hollow  cavity; 
but  if  it  be  an  odontoma,  solid  structure  is  met.  The  non- 
eruption  of  adjacent  teeth  denotes  odontoma. 

Treatment. — The  coronary  odontoma  need  not  be  interfered 
with,  since  it  causes  no  inconvenience.  In  all  cases  in  which  the 
growth  causes  no  pain,  non-interference  should  be  the  rule;  but 
if  pain  be  present,  the  tooth  should  be  removed.  Also,  if  the 
odontoma  be  contained  within  the  maxilla  and  a  fistulous  open- 
ing lead  to  it,  then  an  opening  should  be  made  through  which 
the  odontoma  can  be  removed;  and  in  this  work  it  is  sometimes 
required  to  remove  with  a  chisel  or  forceps  a  portion  of  the  con- 
taining alveolar  wall. 


754 


MAXILLA    IXl'KKIoi:. 


Fibroma. — Fibroma,  as  a  very  infrequent  growth,  has  been 
observed  in  the  u})i)er  and  lower  jaws;  it  has  been  seen  more  fre- 
quently in  the  inferior  maxilla.  In  site  it  is  included,  or  seated 
within  the  bone;  and  thus  it  resembles  the  odontoma  and  the 
maxillary  cystic  tumor;  and  this  analogy  has  led  to  confusion  and 
controversy  in  regard  to  the  origin  of  the  fibroma.  It  is  akin 
to  the  fibro-plastic  species  of  epulis.  Its  development  corresponds 
to  the  period  of  second  dentition;  and  but  little  })ain  is  caused 
by  it  unless  it  encroaches  on  a  nerve.  In  the  upper  jaw  it  may 
partially  obstruct  a  nostril,  or  wholly  occlude  the  lachrymal 
canal.  In  the  lower  jaw  the  fibroma  may  prevent  the  closure 
of  the  teeth,  and  thus  interfere  with  mastication.  Luxation  of 
the  lower  jaw  has  thus  arisen.  The  teeth  implanted  in  such 
tumor  stand  in  divergent  irregularity,  and  finally  fall  from  tlieir 
gockets. 

The  maxillary  fibroma  can  attain  great  dimensions,  and  then 
cause  extreme  deformity  of  the  face.  An  example  of  this  was 
seen  by  Bauchot  in  which  the  lower  jaw  attained  an  immense 
volume,  as  is  shown  in  the  adjacent  sketch  of  the  patient.     Grow- 


FiGUKE  90.    Showing  an  enormous  maxillary  fibroma  observed  by  Bauchot. 

ing  towards  the  neck,  it  may  encroach  on  the  air-passages  and 
obstruct  breathing.  And  if  it  prevents  clo.su re  of  the  mouth,  it 
allows  the  saliva  to  escape,  and  thus  weakens  the  patient.     The 


EPULIS.  Too 

mucous  membrane  covering  it  remains  intact,  and  is  pale  in  color. 
It  is  hard  to  the  touch;  less  so  than  the  odontoma,  and  more  so 
than  a  cystic  tumor;  and  it  becomes  of  larger  volume  than  the 
cj'st.  The  adjacent  glands  remain  unaffected.  If  thoroughly 
removed  it  is  non-recurrent;  and  should  it  return,  it  would  be 
evidence  that  the  tumor  was  not  a  pure  fibroma,  but  of  epuloid 
rather  than  of  fibroid  character. 

The  fibroma  should  be  removed;  and  the  facility  of  doing 
this  will  vary  according  as  the  tumor  is  sessile,  partly  peduncu- 
lated, or  wholly  pedunculated.  The  tumor  must  be  circumscribed 
at  its  attachment,  and  the  removal  be  done  as  close  as  possible 
to  the  bone ;  for  if  a  fragment  be  left,  from  this  a  new  fibromatous 
production  will  probably  arise.  In  case  the  growth  be  included 
within  the  maxillary  structure,  then  the  bone  must  be  opened 
and  the  tumor  thus  extracted;  and  should  this  be  in  the  lower 
jaw,  the  removal  may  require  the  division  of  the  body,  or  a  pro- 
cess of  the  bone,  so  that  a  false  joint  will  result.  But  should  the 
tumor  be  included  in  the  upper  jaw,  the  accompanying  mutila- 
tion will  be  of  less  import  than  in  the  lower  jaw;  in  the  latter 
an  attempt  should  be  made  to  restore  the  interrupted  continuity 
by  metallic  ligature.  After  this  ligation  an  attempt  should  be 
made  to  put  the  part  at  rest  by  a  properly  devised  splint;  and 
for  this  purpose  the  surgeon  may  select  one  of  the  appliances 
employed  in  the  treatment  of  fracture  of  the  inferior  maxilla. 

Osteoma. — Exostosis  sometimes  occurs  in  the  maxillary  bones. 
It  is  round  or  lobulated  in  form,  and  is  not  adherent  to  the  skin ; 
and  if  one  thrusts  into  it  a  needle,  this  will  be  arrested  by  the  hard 
bony  structure.  In  site  this  growth  may  be  central  or  peripheral ; 
that  is,  an  enostosis  or  an  exostosis.  The  exostosis  that  is  sub- 
jjeriosteal  in  its  site,  is  the  more  frequent  one;  it  is  oftenest  in 
the  young;  and  may  originate  in  a  dental  non-suppurating 
periostitis.  Such  osseous  growth  has  been  seen  near  the  inferior 
dental  foramen.  These  osseous  growths  rarely  demand  treat- 
ment; but  if  they  trammel  mastication,  or  are  an  inconvenience 
to  the  patient,  they  should  be  removed;  and  for  this  purpose 
chisel  and  mallet  or  bone  forceps,  are  instruments  with  which  the 
work  can  be  done. 

Epulis. — This  name,  etymologically,  refers  to  a  growth  seated 
on  the  gum  of  the  upper  or  lower  jaw.  The  term  has  been  used 
somewhat  vaguely,  since  it  has  been  employed  to  represent 
tumors  which  vary  in  point  of  origin,  and  in  elementary  struc- 
ture. 


7.")'')  MAX  11. LA    INFERIOR. 

Ill  1868,  Fouilloux  stated,  as  the  result  of  his  studies  of  epulis, 
that  its  place  of  origin  may  be  cue  of  the  following  })oints:  (1)  it 
can  s[)ring  from  the  medullary  canal  of  the  jaw;  and  this  form 
may  a})pear  as  late  as  the  thirtieth  year.  (2)  It  may  arise  from 
the  periosteal  covering  and  submucous  tissue  of  the  alveolar  pro- 
cess near  the  roots  of  the  teeth.  (3)  It  may  originate  from  the 
neuroglia,  or  constituent  tissue  of  the  pulp  of  the  teeth;  and 
here  tlie  growth  is  similar  to  a  myxoma.  (4)  It  can  grow  from 
the  epithelial  coating  of  the  gums,  or  from  that  of  the  cheek.  (5) 
An  eiiulis  may  proceed  from  the  numerous  glands  situated  in  the 
structure  of  tlie  gums.  Fouilloux  saw  cases  of  purely  epithelial 
origin. 

Studied  histologically,  epulis  may  be  divided  into  two  classes, 
viz.,  the  fibro-plastic  and  the  myeloid.  The  fibro-plastic  species 
consists  of  fibroid  elements,  and  it  springs  from  the  periosteum; 
or  if  it  commences  in  the  gum,  it  soon  reaches  to  the  periosteum. 
It  is  composed  of  elongated  spindle-shaped  cells;  and  among 
these,  multi-nuclear  round  cells  occur. 

The  myeloid  species  presents  cells  of  two  kinds:  the  round, 
simple  nucleated  cell,  and  the  giant  cell,  in  which  the  large  cell 
may  be  viewed  as  compounded  of  several  rounded,  nucleated  cells, 
inclosed  in  one  common  enveloping  cell.  In  this  species,  as  well 
as  in  the  fibro-plastic,  one  finds  but  little  inter-cellular  material. 
In  the  myeloid  species  vessels  are  developed;  and  more  so  than 
in  the  fibro-plastic  species.  In  a  few  cases  observed,  vessels  have 
been  formed  so  abundantly  tliat  pulsation  was  perceptible  in  the 
growth.  The  epulis  is  usually  soft  in  texture,  and  of  a  violet 
color;  exceptionally  its  structure  is  hard  and  resistant. 

The  epulis  may  be  sessile  or  pedunculated;  in  the  former,  it 
occupies  a  larger  space  than  in  the  latter,  in  which  the  growth 
may  so  jiroject  from  its  alveolar  origin  that  it  is  movable.  It 
a))pears  equally,  in  the  upper  and  lower  jaw;  and  its  site  on  the 
gum  may  primarily  be  on  the  inside,  or  on  the  outside  of  the 
teeth  ;  and  in  each  case  it  tends  to  grow  towards  the  other  side. 
It  may  arise  between  two  teeth;  and  Dolbeau  claims  that  the 
common  point  of  origin  is  the  osseous  wall  or  ridge  which  sepa- 
rates two  dental  alveoli. 

When  the  growth  is  of  hard  texture,  and  of  a  bright  red 
color,  it  is  of  the  fibro-plastic  species;  but  when  it  is  soft  and  of  a 
dark  red  or  violet  hue,  then  it  belongs  to  the  myeloid  class,  and 
arises  from  the  bone;  and  if  the  tumor  pulsates,  this  is  further 
proof  that  the  growth  belongs  to  the  myeloid  species. 


EPULIS.  757 

The  writer  has  seen  several  cases  of  the  disease;  these  were 
always  in  the  young  subject;  viz.,  in  those  between  six  and 
twenty-four  years  of  age;  and  all  the  cases  w^ere  females  except 
one.  The  growth  was  nsuall}^  in  the  lower  jaw,  and  in  the 
region  of  the  incisor  teeth.  The  teeth  were  sound,  and  the  gums, 
outside  of  the  affected  portion,  were  also  sound.  The  growth  was 
first  observed  as  a  swelling  of  the  point  of  the  gum  which  lies 
between  two  teeth.  This  swollen  tissue  was  of  a  purplish  hue, 
softer  than  the  normal  tissue  of  the  gum;  and  free  from  pain, 
even  when  pressed  between  the  fingers;  and  pressure  did  not 
cause  bleeding,  as  would  occur  in  a  gum  affected  with  scurvy  or 
other  disease.     No  glandular  enlargement  was  present. 

Excepting  this  neoplasm,  the  health  of  the  subject  of  epulis  is 
perfect;  and  in  consequence  of  this,  as  w^ell  as  of  the  painlessness 
of  the  growth,  the  patient,  if  an  adult,  rarely  applies  for  surgical 
aid  until  the  tumor  has  attained  such  dimensions  that  it  inter- 
feres with  mastication. 

Treatment. — Epulis  has  been  classed  as  a  semi-malignant 
neoplasm;  and  ma}'  be  viewed  as  a  growth  located  in  the  line 
which  separates  malignancy  from  non-malignancy,  with  a  root 
springing  from  each  field.  AVith  such  nature,  as  thus  figuratively 
conceived,  the  treatment,  to  be  successful,  must  take  into  account 
this  twofold  character.  Unless  the  growth  be  sought  for  and 
extracted  from  its  most  retired  site  of  origin,  it  will  soon  recur. 

Tlie  patient  soliciting  assistance,  whether  child  or  adult, 
usually  has  perfect  incisor  teeth;  and  when  told  that  some  of 
these  must  be  sacrificed,  not  unfrequently  there  is  a  revolt  against 
such  a  proposition;  such  has  been  the  writer's  experience;  and 
the  patient  then  following  less  radical  tre^Jtment,  has  not  only 
failed  to  be  cured,  but  has  found  herself  in  a  much  worse  condi- 
tion; the  disease,  through  extension,  finally  involving  teeth  which 
were  previously  unaffected. 

A  permanent  cure  can  only  be  secured  by  an  operation  in 
which  the  affected  section  of  the  alveolar  process  with  the  teeth 
contained  in  it,  is  excised.  This  operation  was  practiced  by 
Mutter,  of  Philadelphia,  as  early  as  1850.  His  plan  is  to  first 
extract  a  sound  tooth  on  each  side  of  the  growth;  and  through 
the  gaps  thus  made,  a  vertical  cut  is  to  be  made  with  cutting- 
forceps;  and  then,  having  horizontally  divided  the  soft  parts  with 
a  scalpel,  the  bone  is  to  be  severed  with  cutting  forceps.  Instead 
of  forceps,  the  writer  has  used  a  small  resection  saw;  and  thus  a 
smooth  surface,  and  one  more  favorable  to  immediate  healing,  is 


7o8  MAXILLA    INFLmOR. 

obtained.  Siiould,  however,  there  be  doubt  whether  the  affected 
part  has  wholly  been  removed,  the  wound  may  be  touclied  with 
the  ferruni  candens,  and  allowed  to  heal  by  i^ranulation. 

The  author,  before  proceeding  to  this  mutilating  process,  has 
attenjpted  to  destroy  the  growth  by  the  actual  cautery;  and 
though  the  cauterization  was  thoroughly  done,  gum  nnd  inter- 
dental tissue  being  charred  by  heat,  yet  there  was  invarial^ly  a 
recurrence;  and  tlie  only  advantage  from  it  was,  that  it  made  the 
patient  submit  more  contentedly  to  the  radical  excision  just 
described. 

Though  one  or  more  teeth  be  lust,  the  maxillary  arcli  remains 
so  that  artificial  teeth  can  be  placed  in  the  breach. 

Malignant  Growths. — Sarcoma,  chondroma  and  carcinoma 
ap^jcar  in  both  the  upper  and  lower  jaws.  Sarcoma  of  an  epuloid 
ty2)e  is  not  infrequent;  in  fact,  the  myeloid  species  of  ei>ulis  so 
closely  resembles  sarcon'ia  that  the  two  terms,  as  reciprocals  might 
replace  each  other.  There  arises  here,  as  in  many  sections  of 
surgery,  a  temptation  to  reconstruct  the  existing  nomenclature. 
The  example  of  the  well-planned  efforts  of  such  innovation  by 
Piorry,  Leidy  and  otliers,  of  wliich  l>ut  fragmentary  traces  have 
escaped  oblivion,  warn  the  prudent  writer  not  to  waste  effort  in 
tr\'ing  to  check  the  powerful  current  of  u.sage;  and  thus  conserv- 
atively proceeding,  myeloid  epulis  may  be  viewed  as  a  species 
or  cognate  form  of  sarcoma. 

Chondroma  in  the  maxillary  region  is  closely  akin  to  the 
cancerous  growth.  It  occurs  oftenest  in  the  Highmorian  sinus  of 
the  upper  jaw;  yet  it  occurs  also  in  the  inferior  maxilla;  and 
here  its  origin  may  be  central,  the  chondroma  beginning  within 
the  bone;  or  it  may  start  })eripherally ;  and  then  it  commences  in 
.the  periosteum,  A  tumor  which  begins  latently,  and  forces  its 
way  thi'ough  the  bone  without  causing  ulceration,  and  is  of 
tuberous  outline,  often  containing  cystic  compartments,  is  a 
central  (diondroma.  But  when  the  tumor  is  of  periosteal  origin, 
its  nature  becomes  apparent  at  a  much  earlier  period.  Tlie 
chondroma  sliould  bo  extirpated;  and  care  must  be  used  to 
remove  the  growtli  in  its  entirety;  and  to  be  assured  of  this,  the 
operator  must  carr}--  the  line  of  excision  well  into  the  contiguous 
sound  structure. 

Carcinoma. — Cancerous  growth  of  the  type  of  epithelioma  may 
appear  primarily  in  both  the  upper  and  lower  jaw;  or  the  disease 
may  occur  secondarily  through  propagation  from  neighboring 
[)arts.     "When  it  is  a  primitive  growtli,  the  disease  commences  in 


CAKCIXOMA.  759 

the  mucous  surface  of  the  gum,  or  in  the  periosteal  covering  of 
the  bone.  When  it  begins  in  the  mucous  snriace,  its  develop- 
ment is  similar  to  that  of  epithelioma  elsewhere;  thickening  of 
surface  is  finally  succeeded  by  ulceration  that  penetrates  gradually 
to  the  bone.  Such  disease,  from  the  writer's  experience,  often 
appears  Ijehind  the  incisors  of  the  lower  jaw,  and,  burrowing 
inwards,  finally  attacks  the  alveolar  process,  and  exposes  the 
roots  of  the  teeth,  which  remain  in  place  until  the  alveolar 
structure  which  contains  them  has  been  destroyed. 

The  carcinoma  originating  in  the  periosteum  grows  somewhat 
diflferently  from  that  just  mentioned;  in  the  growth  of  the  tumor, 
the  periosteum  is  detached  from  the  bone  at  an  early  period,  and 
thus  its  osteo-genetic  action  is  stimulated,  and,  as  result,  new 
bone  is  caused  to  grow.  In  this  way  osteophytes  are  produced 
which  become  a  part  of  the  tumor. 

Carcinoma  occurs  in  those  who  are  advanced  in  age;  the 
reverse  of  which  is  the  case  with  chondroma  and  sarcoma. 
Carcinoma  occurring  primarily  in  the  maxilla  develops  rapidly: 
often  within  six  months  from  the  commencement  of  the  growth; 
it  comprises  within  its  domain  the  entirety  of  the  jaw,  and  the' 
adjacent  parts  becoming  implicated,  are  hard  in  texture,  increased 
in  volume,  and  lose  their  accustomed  mobility.  The  infiltrated 
structures  soon  ulcerate,  and  ichorous  fluid  and  particles  of  the 
decaying  structures  are  discharged.  In  epuloid  sarcoma  and 
chondroma,  there  is  little  or  no  glandular  infection;  but  in 
carcinoma  the  neighboring  glands  become  affected  at  an  early 
period,  and,  in  their  voluminous  growth,  they  add  greatly  to  the 
tumefaction  of  the  soft  structures;  this  applies  specially  to  the 
lymphatic  glands  which  lie  within  the  arch  of  the  inferior 
maxilla. 

As  means  of  diagnosis,  a  harpoon-like  instrument  can  be 
thrust  into  the  growth,  and,  a  fragment  being  withdrawn,  a  micro- 
scopic examination  will  determine  the  nature  of  the  tumor. 
From  the  writer's  experience,  the  microscope  when  questioned  in 
regard  to  the  nature  of  growths,  frequently  gives  a  Delphic 
response,  one  that  can  be  interpreted  as  much  for  as  against 
malignancy.  In  fact,  the  true  nature  of  the  growth  is  to  be 
learned  from  a  study  of  its  clinical  history;  and  in  this  inquiry, 
macroscopic  rather  than  microscopic  evidence  should  be  given 
precedence.  A  hard  tumor  fastened  to  the  bone,  so  immovable,  in 
fact,  that  it  simulates  an  exostosis;  and  which  is  usually  painless 
until  it  ulcerates;  and  is  of  rapid  growth,  and  accompanied  by 


7(JU  MAXILLA    INFERIOR. 

earlv  glandular  infection:  such  are  the  historical  elements  of 
maxillary  carcinoma:  a  history  clearly  intelligible  to  experience; 
and  in  such  a  case,  the  microscope  would  furnish  confirmation, 
redundant  rather  than  necessary. 

Treatment. — The  only  possible  relief  for  a  patient  of  carci- 
noma springing  from  the  maxillary  bones  lies  in  an  excision 
of  the  atft'Cted  bone;  and  this  to  be  effective,  must  be  done  early. 
For  after  the  glands  have  become  largely  swollen,  or  the  soft  parts 
are  perforated  by  ulcerative  action,  the  disease  has  obtained 
indisputable  hold  of  the  patient's  life,  and  any  operation,  how- ■ 
ever  thorough  it  may  be  done,  will  prove  but  a  mutilation. 
An  oi)erative  attempt  then  made,  instead  of  ameliorating  the 
jtatient's  condition,  will  only  prove  an  ally  of  the  disease;  and 
the  final  result  will  probably  be  an  abridgment,  rather  than  an 
extension  of  life;  since,  through  surgical  lesion,  a  wider  field  for 
cancerous  devastation  will  be  laid  open.  Hence,  as  a  cardinal 
rule  of  treatment,  remove  the  affected  structure  as  soon  as  the 
disease  is  recognized:  and  this  introduces  the  study  of  excision 
of  the  inferior  maxilla. 

Excision  of  the  lower  jaw  has  awaicened  and  stimulated  surgi- 
cal ingenuity,'  and  from  mutual  emulation  to  improve  the  meth- 
ods, numerous  rival  procedures  have  arisen.  As  famous  pioneers 
in  the  work  were  Gensoul,  Syme,  Be'gin,  Forget,  Heyfelder  and 
Schillbach. 

The  excision  may  be  partial  or  total  according  to  the  extent 
of  the  disease,  viz.,  the  operation  may  only  embrace  one  side; 
or  the  median  or  mental  portion  may  be  exsected;  or  the  max- 
illa in  its  entirety  may  be  removed.  In  the  removal  of  the  greater 
part,  or  of  the  whole  of  the  lower  jaw,  there  is  encountered  an 
unexpected  difficulty,  to  wit,  the  regression  or  retroversion  of  the 
tongue  and  retraction  of  the  structures  in  the  maxillary  cavity, 
whereby  the  patient  may  be  suffocated;  this  does  not  occur  in 
partial  excision  unless  the  part  which  is  removed  be  the  anterior 
median  portion. 

The  methods  which  have  been  used  for  unilateral  or  partial 
excision,  will  first  be  considered.  In  1842,  Syme  did  this  work 
through  a  cut  described  by  him  as  follows:  "The  best  course  for 
incisions  through  the  cheek  is  first  downwards  from  that  angle  of 
the  mouth  which  is  opposite  a  sound  part  of  the  jaw,  and  then 
along  the  base  as  far  as  the  tumor  extends;  and  if  necessary,  up 
along  the  posterior  ramus  to  the  condyle.  The  flap  thus  formed 
having  been  separated  from  the  tumor,  the  jaw  is  partially  cut 


CARCINOMA.  761 

through  with  a  small  saw,  and  tlieii  completely  divided  by  strong 
cutting  pliers.  The  surgeon  then  grasping  the  detached  portion 
turns  it  outwards,  and  separates  its  connection  witli  the  muscles 
and  membrane  of  the  mouth.  .  .  .  The  only  arteries  that 
require  to  be  tied  are  the  facial  and  the  transverse  branches  of 
the  temporal."  And  should  it  be  required  to  remove  the  ramus, 
the  temporal  muscle  must  be  divided,  so  that  the  joint  can  be 
exposed;  the  knife  is  then  to  be  "carried  close  around  the  condyle, 
so  as  to  avoid  the  internal  maxillary  artery,  which  crosses  the 
neck  of  this  process  on  its  inner  surface,  about  a  half  an  inch 
below  the  joint."  The  amount  of  deformity  which  follows  exci- 
sion of  a  greater  part  of  the  lower  jaw  was  found  by  Sj'me  to  be 
smaller  than  could  be  conceived  without  actual  observation;  and  ' 
on  this  account,  as  well  as  on  account  of  the  relief  which  it 
afforded  the  patient,  "the  operation  may  be  regarded  as  one  of 
the  greatest  improvements  in  modern  surgery." 

In  1850,  Huguier  advised  to  make  a  cut  for  excision,  which 
should  lie  horizontal,  below  and  parallel  with  the  duct  of  Steno; 
thus  flaps  were  made  which  were  reflected  upwards  and  down- 
wards; through  this  cut  the  bone  having  been  sawed  through, 
half  of  the  jaw  can  be  removed  without  injury  to  the  facial  nerve. 

J.  F.  Heyfelder  and  his  son,  Oscar,  were  early  operators  in 
this  field;  in  1857  the  latter  wrote  on  the  maxillary  excision  a 
monograph,  in  which  is  found  a  review  of  the  work  done  by 
his  father  and  others.  He  wrote  that  prior  to  1843,  excision  of 
the  lower  jaw  was  feared  on  account  of  the  nearness  of  the  carotid 
artery,  and  suffocation  from  retraction  of  the  tongue;  and  to 
lessen  the  dangers  where  total  excision  was  done,  in  1843,  Sig- 
norini  removed  one-half,  and  at  a  later  period  he  ventured  to 
remove  the  other.  After  this,  total  excision  was  done  by  Pitha, 
He3'felder,  Dumreicher,  Maisonneuve  and  Carnochan.  In  1853 
Heyfelder  removed  the  entire  jaw,  after  having  divided  the  bone 
at  the  symphysis.  The  incision  of  Heyfelder,  similar  to  that  of 
Huguier,  before  mentioned,  commenced  at  the  angle  of  the  mouth 
and  passed  straight  backwards,  stopping  two-fifths  of  an  inch 
anterior  to  the  lobule  of  the  ear.  The  bone  being  divided  in 
front,  it  is  separated  from  the  soft  parts  by  a  blunt  dissector  by 
which  vessels  are  spared :  the  facial  artery  only  need  be  severed. 
In  severing  the  external  pterygoid  muscle,  one  must  be  careful 
to  avoid  the  internal  maxillary  artery.  For  a  time  the  work  was 
done  without  dividing  the  lower  lip.  Instead  of  the  high  hori- 
zontal cut,  Langenbeck  made  one  along  the  lower  margin  of  the 
49 


762  MAXILLA   INFEKIOR. 

maxilla  to  the  angle,  and  thence  upwards  to  opposite  the  tongue. 
Maissonneuve  also  incised  along  the  lower  edge  of  the  maxilla, 
yet  he  did  not  continue  his  cut  upwards  on  the  ramus.  In  the 
plan  of  Maisonneuve  it  is  difficult  to  reach  the  summit  of  the 
ramus  and  divide  the  muscles  there.  Verneuil  followed  this 
plan,  and,  having  sawed  the  bono  through  in  front,  he  caught  hold 
of  this,  and  i)ulling  violently,  he  severed  the  muscles  attached  to 
the  ramus.  But  others  condemn  this  mode  of  extraction  as  peril- 
ous to  the  vessels.  Chassaignac  reported  a  case  in  which  the 
internal  carotid  was  thus  ruptured.  Though  the  periosteum  i)0 
preserved  by  this  method,  it  is  rare  that  new  bone  has  been 
re-formed. 

Forget,  also  an  authority  on  maxillary  excision,  directs  that 
special  care  be  used  in  dividing  the  bone;  the  sawing  should  be 
so  done  that  no  sharp  angles  can  pierce  through  the  overlying 
soft  parts.  And  should  the  lip  be  the  site  of  cancer,  Forget 
directs  that  this  should  first  be  removed  and  the  flaps  for  closure 
be  constructed,  before  the  bone  is  severed.  As  soon  as  the 
divided  bone  has  been  detached  from  its  site,  extensive  bleeding 
will  occur  from  the  sublingual  region;  and  this  bleeding,  which 
is  arterial  and  venous,  should  be  controlled  by  ligature.  To 
guard  against  and  to  be  able  to  control  such  haemorrhage, 
Dupuytrcn  did  not  close  the  wound  for  at  least  an  hour. 

Schillbach,  an  exhaustive  writer  on  this  subject,  describes  the 
operation  for  partial  and  total  excision  of  the  maxilla  inferior. 
For  unilateral  removal  he  advises  to  begin  the  incision  in  front 
of  the  ear,  and  carry  this  down  to  the  angle,  and  thence  along 
the  lower  margin  to  the  symphysis;  then  saw  through  and  detach 
the  soft  parts  from  before  backwards;  in  this  dissection  spare  the 
inferior  dental  nerve  and  artery,  until  the  soft  parts  beyond  are 
separated;  lastly,  se\'er  the  artery  and  nerve,  and  tie  the  bleeding 
vessels.  The  steps  are  similar  where  the  entire  bone  is  removed. 
The  vertical  cut  should  not  be  carried  beyond  the  lobule  of  the 
ear;  thus  the  facial  nerve  and  parotid  gland  are  left  uninjured. 
Schillbach  advises  also  to  avoid  tlie  division  of  the  facial  vein ;  for 
if  this  be  cut  and  tied,  much  swelling  from  retained  blood  will 
ensue. 

The  later  operators  counsel  that  in  doing  the  operation  the 
mucous  membrane  of  the  mouth  should  be  opened  as  little  as 
possible;  and  that  this  opening  be  made  late  in  the  work.  As 
a  method  more  conservative  than  any  which  has  been  men- 
tioned, Larghi  did  the  excision  wholly  through  the  mouth  w'ith- 


CARCIXOMA.  763 

oat  any  external  incision;  also,  Heyfelder  excised  in  this  way,  in 
some  of  his  later  work. 

Despite  the  encomium  passed  on  inferior  maxillary  excision 
by  Syme,  it  has  its  shadowy  side;  during  the  operation,  and  for 
some  days  afterwards,  there  is  danger  of  suffocation  from  lingual 
retraction;  also,  the  face  is  greatly  deformed.  These  points  will 
next  be  considered. 

Lingual  retraction  after  removal  of  the  lower  jaw  has  been  the 
subject  of  study  by  Begin,  who  thinks  that  tlie  operation  destroys 
the  equilibrium  of  the  muscles  which  surround  the  larynx  and 
pharynx,  so  that  these  parts  tend  to  close;  and  this  is  mainly 
done  by  the  posterior  muscles,  which,  pulling  on  tlie  larynx  and 
hyoid  bone,  cause  their  convex  surface  to  look  upwards.  The 
effect  of  such  action  is  to  lift  tlie  anterior  end  of  the  glottis  up- 
wards, so  tliat  the  fissure  of  the  glottis  stands  vertical;  and  in 
such  position  the  air  can  hardly  enter  it. 

Asphyxia  from  lingual  retraction,  according  to  Begin,  may  be 
primary  or  secondary;  the  primary  takes  place  within  forty-eight 
hours,  while  the  secondary  occurs  at  any  time  afterwards,  ujitil 
the  muscles  have  become  securely  cicatrized;  and  this  secondary 
retraction  has  occurred  most  unexpectedly,  when  the  patient  was 
considered  out  of  danger.  To  guard  against  this  accident  some 
surgeons  have  passed  a  thread  through  the  tongue  and  fastened 
this  to  the  teeth.  This  plan  is  not  favored  by  Begin:  he  advises 
to  place  a  wire  framework,  similar  to  a  mask,  around  the  head, 
and  to  tie  the  thread  to  this,  in  front.  He  advises  not  to  close  the 
wound  perfectly;  he  would  leave  the  lateral  cuts  open;  exact 
closure  in  the  antero-posterior  direction,  he  claims,  tends  to  force 
the  tongue  backwards. 

Heyfelder  finds  that  the  position  of  the  head  has  much  to  do 
in  producing  lingual  retraction ;  he  observed  that  it  occurred  when 
the  patient  lifted  his  head,  yet  that  retraction  disappeared  when 
he  lowered  the  head  towards  the  sternum.  He  passed  a  thread 
through  the  tongue,  and  committed  the  charge  of  this  to  a  nurse; 
meantime  he  placed  the  patient  on  the  side. 

Pitha,  who  made  a  study  of  this  subject,  thinks  lingual  retrac- 
tion is  not  a  mere  passive  act,  but  that  it  is  due  to  a  spasmodic 
action  of  the  muscles;'  and  so  violent  was  this  in  one  case,  that 
the  tongue  could  not  be  lield  by  a  ligature  which  passed  through 
it;  and  to  accomplish  fixation  a  pair  of  bulldog  forceps  was  used. 

The  lingual  retraction  in  a  case  operated  on  by  the  writer  was 
counteracted  by  passing  a  ligature  through  the  tongue,  and  then 


7G4  MAXILLA    JXFKKIOK. 

attaching  this  to  a  baud  whicli  j)assed  behind  the  head;  and  in 
another  case,  the  retaining  cord  was  tieil  around  the  ear,  and  then 
a  strip  of  adhesive  plaster  was  jjUiced  around  tiie  licad  and  on  the 
ear  so  that  the  cord  was  retained  securely  in  its  place. 

Sprengler,  in  1SG4,  writing  on  total  excision  of  the  lower  jaw, 
remarks  that  if  th.o  entire  bone  be  removed,  the  soft  parts  retract 
backwards,  until  they  are  almost  on  a  level  with  the  underlying 
larynx.  Also,  considerable  deformity  will  result  if  only  one  side 
of  the  anterior  median  portion  be  removed.  Langenbeck  has 
sought  to  avoid  this  deformity  by  removing  the  bone  in  sections 
at  different  times.  He  also  tried  to  avoid  deformity  by  dividing 
the  bone  that  was  to  be  excised  into  two  parts;  and  then  removing 
one  portion,  he  loft  the  other  to  supply  its  place.  Thus,  in  such 
a  case,  hes})lit  the  ramus  into  two  jKirts,  and  then,  having  excised 
one  of  the  latter,  he  shifted  the  remaining  portion  so  that  it  occu- 
}>ied  the  vacant  site  of  the  body  which  had  been  removed. 
Though  the  results  obtained  in  the  case  were  not  all  that  could 
be  wished,  3'et  from  experiments  on  the  cadaver,  Langenbeck 
became  convinced  that  the  work  could  be  satisfactorily  done  in 
this  way. 

Instead  of  doing  the  work  as  done  by  Langenbeck,  others 
have  sought  to  lessen  the  deformity  following  the  inferior  maxil- 
lary excision  by  introducing  some  artificial  appliance  in  the  site 
of  the  excised  bone.  Lecat,  Langenbeck  and  others  tried  this 
plan,  and  mechanical  devices,  similar  to  those  used  by  the  dentist, 
liave  been  tried.  The  material  of  which  the  aj)pliance  was  made 
was  leather,  silver  or  vulcanite,  and  it  was  held  in  place  by 
straps  which  encircled  the  neck  and  head.  The  pain  and  incon- 
venience from  such  substitute  was  so  great  that,  in  most  cases,  the 
patient  would  not  tolerate  it. 

In  closing  this  chapter  on  excision  of  the  lower  jaw,  the  writer 
should  add  that  where  the  whole  or  a  greater  portion  of  the  max- 
illa is  removed,  direful  deformity  of  the  face  is  inevitable,  and  the 
l)ower  to  masticate  food  will  be  lost;  in  the  male,  a  beard  may 
somewhat  mask  the  deformity;  but  the  ability  to  chew  food  will 
be  lost;  and  the  unfortunate  subject  must  afterwards  subsist  on 
nutrient  material  which  is  in  liquid  or  semi-liquid  form.  Yet 
life  with  such  impediments  is  always  accei)ted  by  the  i)atient, 
and  by  him,  as  well  as  by  its  surgical  paternity,  the  attendant 
deformity  is  viewed  with  complacency. 

Anchylosis  of  the  Maxilla  Inferior. — The  buccal  cavity  is  divided 
into  two  compartments  by  the  alveolar  dental  arches:  the  one 


ANCHYLOSIS    OF    THE    MAXILLA    INFERIOR.  765 

space  is  contained  between  the  arches  and  tlie  cheeks  and  lips; 
the  otlier  lies  within  the  arclies,  and  is  the  proper  oral  cavity;  the 
external  one  is  easily  entered,  whether  the  jaws  be  opened  or 
closed;  the  inner  cavity  can  only  be  reached  through  the  separa- 
tion of  the  lower  jaw  from  the  upper  one,  or  by  a  circuitous  route 
behind  the  molar  teeth,  where  the  two  spaces  inter-communicate. 

Normally  the  inferior  maxilla  is  easily  depressed  from  the 
upper  jaw;  yet  the  degree  of  separation  varies  in  difiPerent  mouths, 
as  is  evident  from  the  observation  of  mouths  which  are  opened 
to  their  utmost.  The  limitation  to  opening  may  depend  on 
some  tethering  conditions  existent  in  the  mucous  lining  of  the 
cheeks,  in  the  muscles  composing  the  latter,  in  the  ligaments  con- 
necting the  jaws,  or  in  the  osseous  structures.  And  where  one  or 
more  of  those  limiting  conditions  is  in  excess,  the  lower  jaw  may 
be  immovable,  or  at  least  inseparable  from  the  superior  maxilla; 
that  is,  the  maxilla  inferior  is  anchylosed. 

Bonnet  has  studied  tlie  causes  of  maxillary  anchylosis,  and 
finds  that  it  can  arise  from  an  inflammation  in  the  soft  parts 
around  the  joint;  or  in  the  osseous  parts  composing  the  joint. 
Besides  these  modes  of  origin,  a  more  usual  one  is  ulceration, 
abscess,  or  some  lesion  of  the  oral  cavity;  and,  finally,  it  may  arise 
from  muscular  retraction  and  cicatricial  shortening. 

Schulten,  of  Finnland, in  1879, classified  thecauses  of  anchylosis, 
as  follows:  (1)  Anchylosis  from  disease  in  the  maxillo-temporal 
joint.  (2)  Myogenous  anchylosis,  in  which  immobility  arises 
from  some  abnormal  condition  of  the  muscles.  (3)  Cicatricial 
contraction  dependent  on  ulceration  or  wounds  of  the  mucous 
lining  of  the  oral  cavity.  (4)  Anchylosis  from  some  deformity  of 
the  lower  jaw:  a  species  rarely  met  with. 

The  author  has  seen  a  case  in  which  the  prime  causal  agency 
was  mercurial  gangrene  in  which  the  cheek  was  lost  by  slough- 
ing, due  to  excessive  use  of  calomel. 

Treatment. — For  practical  purposes  the  causes  of  immobility 
may  be  reduced  to  two  classes:  in  one,  it  arises  from  an  abnormal 
state  of  tlie  soft  parts;  and  in  the  other,  it  depends  on  some  abnor- 
mal condition  in  the  osseous  structures;  and  hence  have  arisen  two 
different  plans  of  treatment:  in  one  forcible  separation,  tenotomy, 
myotomy,  and  plastic  procedures  are  resorted  to;  in  the  other, 
relief  is  obtained  through  osseous  division,  or  resection.  Forcible 
dilatation  to  overcome  anchylosis  has  been  done  by  a  double  lever- 
like instrument,  in  which  the  blades  are  separated  by  means  of  a 
screw  which  traverses  the  blades.     And  afterwards,  to  maintain 


7GG  MAXILLA    INFERIOR. 

the  jaws  asunder,  corks  may  be  inserted  between  the  teeth  and 
allowed  to  remain  there.  The  advantage  of  this  plan  of  treat- 
ment is  that  after  the  jaws  have  once  been  separated,  the  patient 
himself  can  continue  the  work  of  separation. 

Among  the  earliest  essays  in  this  section  of  surgery  was  an 
operation  done  by  Blasius,  for  relief  in  a  case  in  wliicli  the  cheeks 
were  grown  to  the  jaws,  whereby  the  inferior  maxilla  became 
immovable.  He  made  a  cut  backwards  from  each  angle  of  the 
mouth,  and  then,  having  dissected  the  cheeks  from  the  jaws, 
through  the  wounds  made  he  next  turned  the  skin  inwards,  and 
attached  it  by  sutures  to  the  wounded  edge,  so  that  closure  of  the 
cuts  was  prevented.  There  was  thus  formed  a  wide  mouth, 
through  which  the  work  of  depressing  the  lower  jaw  was  effected; 
after  mobility  was  secured,  the  wide  mouth  was  reduced  to  nor- 
mal dimensions  by  detaching  the  infolded  skin,  and  uniting  the 
inner  mucous  border  to  the  inner  mucous  border,  and  suturing 
the  derm  above  to  the  derm  below. 

Gussenbauer,  in  1877,  reported  a  case  in  which  he  operated 
for  relief  in  a  patient  in  whom  the  cheeks,  having  become  adher- 
ent to  the  jaws,  caused  the  latter  to  be  immovable.  The  work 
commenced  with  two  incisions,  which  began  at  the  angle  of  the 
mouth  and  extended  backwards  to  the  masseter  muscle;  the  flap 
thus  made  was  folded  inwards  on  itself,  so  that  the  derm  was 
turned  inwards,  and  its  mucous  surface  outwards  and  united  to 
that  of  the  cheek,  the  two  surfaces  having  been  made  raw.  After 
union  of  the  raw  surfaces,  the  flap  was  severed  behind,  and 
unfolded  so  that  its  base  was  carried  forwards,  and  became  the 
commissure  of  the  mouth.  The  disposition  of  the  parts  after- 
wards was  such  that  the  inverted  derm  could  not  cohere  to  the 
jaw,  and  thus  the  lower  jaw  became  separable  from  the  upper  one. 

The  plastic  procedures  of  Blasius  and  Gussenbauer  did  not 
find  many  imitators;  on  the  contrary,  many  operations  w^ere 
reported  in  which  the  work  was  done  subcutaneously,  by  tenotomy 
and  myotomy.  A  brief  review  of  the  methods  pursued  in  this 
work,  will  herewith  follow. 

In  1840,  Mutter,  of  Philadelphia,  did  the  work  of  myotomy  by 
intra-oral  submucous  section  of  the  interior  portion  of  the  mas- 
seter muscle;  the  same  was  done  by  Buck.  Velpeau,  who  tried 
this  plan  in  three  cases,  afterwards  had  recurrence  of  the 
anchylosis. 

The  muscles  on  which  myotomy  was  done  by  those  who 
practiced  this  plan,  were  the  masseter,   the  temporal    and   the 


ANCHYLOSIS    OF    THE    MAXILLA    INFERIOR.  767 

internal  pterygoid.  Bonnet  thinks  that  division  of  the  internal 
pterygoid  muscle  is  unnecessary;  and  that  in  most  cases,  section 
of  the  masseter  is  sufficient;  and  if  not,  then  the  temporal  muscle 
should  be  cut.  Bonnet  advises  that  the  masseter  be  divided  in 
its  upper  portion,  since  there,  tlie  facial  nerves  and  the  duct  of 
Stenson  are  not  endangered  by  the  knife;  besides,  if  section  be 
made  lower  down,  the  muscle  there  is  so  adherent  to  the  bone 
that  relief  would  not  follow  its  division. 

Schmidt  divided  the  masseter  in  its  upper  part,  yet  he  did 
the  work  inside  of  the  mouth;  he  commenced  at  the  anterior 
margin  of  the  muscle,  and  thence  cut  backwards,  meantime 
lifting  the  skin  so  as  to  protect  it  from  injury. 

Fergusson,  also,  performs  myotomy  of  the  masseter,  on  the 
inside  of  the  mouth ;  he  commences  beneath  the  opening  of  the 
parotidean  duct,  and  cuts,  at  first,  but  one-haif  of  the  muscle; 
fourteen  days  afterwards,  he  finishes  the  operation  by  dividing 
the  remainder  of  the  muscle. 

Bouvier  did  the  myotomy  from  the  outside;  after  penetrating 
deeply,  he  cut  towards  the  skin;  he  divided  the  muscle  in  its 
middle,  and  thus  avoided  the  duct  of  Steno.  Bouvier  claims  that 
the  median  section  divides  all  the  fibres  of  the  muscle,  which  is 
not  the  case  if  the  division  be  higher  or  lower. 

In  the  division  of  the  temporal  muscle,  Bonnet  finds  that  the 
work  can  be  done  above  or  below  the  zygoma;  but  the  lower  sec- 
tion is  more  effective,  since  the  tendon  of  the  muscle  is  there 
more  loosely  surrounded  by  connective  tissue.  In  the  old  subject, 
however,  for  example,  in  those  over  thirty  years  of  age,  the  coro- 
noid  process  ascends  so  higli  that  the  temporal  tendon  cannot  be 
reached  below  the  zygomatic  arch.  Also,  where  the  upper  and 
lower  teeth  glide  by  each  other,  section  of  the  tendon  cannot  be 
made  below  the  arch.  The  section  above  tlie  zygoma  is  less 
effective,  since  the  temporal  muscle  there  is  fastened  to  the  bone 
by  its  fibres.  Also,  branches  of  the  temporal  artery  may  be^ 
wounded  there,  and  extensive  ecchymosis  may  ensue.  Fergusson 
made  the  section  from  the  inside  of  the  mouth;  but  Bonnet  did  it 
from  the  outside,  and  cut  both  above  and  below  the  zygoma;  and 
he  penetrated  quite  to  the  bone,  and  tlience  cut  outwards.  In 
section  above  the  arch  the  temporal  artery  must  be  shunned. 

To  sever  the  internal  pterygoid,  Gue'rin  cut  from  the  inside, 
internal  to  the  ascending  ramus;  yet  Fergusson  fears  that  by 
thus  doing,  the  internal  maxillary  artery  and  inferior  dental 
nerve   may  be   severed.     To  sever  the   internal   pterygoid,  the 


708  MAXILLA    INFERIOR. 

writer  would  do  the  work  from  the  outside,  through  a  crescentic 
cut  bordering  the  mandibuhir  angle:  thus  with  the  j»arts  open  to 
view,  the  muscle  can  be  wholly  severed;  and  afterwards,  the 
wound  could  be  closed,  and  united  primarily. 

Jaesche,  of  Xovogorod,  obtained  relief  in  an  anchylosed  jaw  by 
extending  the  oral  commissure  on  the  affected  side  and  forcibly 
opening  the  mouth.  At  a  later  period  he  closed  the  breach  by 
drawinor  the  mucous  and  submucous  tissues  from  above  and 
below  and  uniting  them.  And  in  this  closure,  tlie  work  was  so 
done  that  no  raw  surfaces  were  left  by  which  the  cheek  could 
reunite  to  the  jaws. 

Sprengler  reports  the  cure  of  a  case  in  wliich  he  divided  the 
scar  and  subsequently  placed  corks  between  the  jaws  to  maintain 
separation ;  and  as  aid,  he  also  severed  the  masseter  muscle. 

In  1858,  Wilms,  of  Berlin,  reported  a  case  of  anchylosis  of  the 
lower  jaw,  in  which,  having  tried  ineffectually  various  modes  of 
treatment,  he  divided  the  bone  on  the  right  side,  one  and  one- 
half  inches  from  the  median  line,  and  then  he  removed  a  seg- 
ment of  the  jaw  over  an  inc-li  long.  Thus  a  gap  was  formed 
which  filled  with  fibrous  tissue,  and  a  pseudarthrosis  remained. 
The  patient's  condition  was  so  improved  that  he  afterwards 
could  chew  with  the  left  side  of  the  jaw.  AVilms'  claim  for 
priority  in  originating  this  method  was  assailed,  and  it  was 
shown  that  Bruns  had  operated  thus  three  years  previously,  and 
also  that  Dieffenbach  had  advised  to  form  a  false  joint  in  such 
cases. 

In  1860,  Verneuil,  in  anchylosis  of  the  lower  jaw  that  could 
not  be  overcome  by  any  other  means,  divided  the  maxilla  with 
Liston's  forceps  at  a  point  corresponding  to  the  insertion  of  the 
masseter  muscle. 

In  1800,  Esmarch  wrote  exhaustively  on  this  subject,  and  he 
gives  the  credit  to  Dieffenbach  of  introducing  the  plan  of  coat- 
ing with  mucous  membrane  the  raw  surfaces  made  in  the  work 
of  liberation.  Esmarch  reviews  the  methods  of  osteotomy 
which  have  been  resorted  to  where  the  work  could  not  be  accom- 
plished by  division  of  the  contracted  soft  parts.  He  notes  that 
Bruns  and  others  made  an  artificial  joint,  yet  the  error  was  usu- 
ally committed  by  these  operators  of  making  the  false  joint 
behind  instead  of  before  the  binding  tissue,  and  hence  the  jaw 
remained  afterwards  as  functionless  as  it  was  before. 

The  germinal  idea  of  creating  a  pseudarthrosis  for  relief  in 
cases  of  pseudarthrosis  is  referred  by  Verneuil  to  Rhea  Barton. 


ANCHYLOSIS    OF    THE    MAXILLA    INFERIOR.  769 

of  Philadelphia,  who  performed  such  an  operation  above  the 
knee.  As  an  early  ally  in  the  work  Carnochan  may  be  men- 
tioned, who,  in  1845,  after  division  of  the  masseter,  in  attempt- 
ing to  open  the  jaw,  fractured  it,  and  found  this  an  aid  in  the 
matter  of  movement. 

In  1860,  Rizzoli  announced  an  operation  in  which  he  sepa- 
rated the  soft  parts  within  the  mouth,  and  then  iie  divided  the 
maxilla  through  the  site  of  a  bicuspid  tooth,  or  through  that  of 
the  first  molar;  this  division  was  made  with  the  saw,  or  Liston's 
forceps,  without  sacrifice  of  bone,  and  the  result  obtained  was 
satisfactory. 

In  1865,  Mathd  reported  a  number  of  operations  for  relief  of 
maxillary  anchylosis.  In  seven  cases  in  which  there  was  no  loss 
of  the  skin  as  causal  agency,  he  simply  sawed  through  the  max- 
illa; of  these  six  were  cured.  But  in  six  cases  in  which  there 
had  been  structural  loss  of  the  cheek  two  recovered,  three  died, 
and  one  was  a  failure.  Mathe'  reports  tliat  after  resection  or 
division  of  the  jaw,  relapse  not  unfrequently  occurred. 

Math ^  specifies  the  point  as  most  proper  for  tlie  division  to 
be  between  the  last  molar  and  the  wisdom  tooth.  In  this  oper- 
ation, he  divided  and  uplifted  the  mucous  membrane  and  peri- 
osteum, so  that,  after  the  bone  was  divided,  these  structures  could 
be  replaced,  and  the  wound  in  the  bone  covered.  In  case  some 
plastic  work  is  rec[uired,  this  should  be  done  some  time  after  the 
artificial  joint  has  been  formed. 

In  1885,  Ranke,  of  Groningen,  reported  operations  done  by 
the  method  of  Bottini:  this  consisted  in  an  incision  along  the 
lower  edge  of  the  zygoma,  over  one  inch  in  length,  and  to  this  a 
vertical  cut  is  to  be  made  an  inch  in  extent.  Next,  detach  the 
masseter  from  the  zygoma,  and  dissect  down  to  the  condyle; 
then  saw  this  through  its  neck  and  remove  the  condyle.  And 
in  some  cases  it  is  well  to  divide  the  coronoid  process.  The 
writer  thinks  this  plan  could  be  resorted  to  with  advantage  in 
patients  in  whom  the  causal  agency  is  in  or  near  the  maxillo- 
temporal  joint. 

In  operations  for  relief  of  maxillary  anchylosis,  if  an  anses- 
thetic  be  used,  this  should  be  carefully  watched,  since  the  tongue 
falling  backwards  mav  cause  strangulation.  Ranke  says  that 
one  patient  was  thus  lost. 

In  whatever  way  the  treatment  of  maxillary  anchylosis  is 
pursued,  the  subsequent  orthopedic  work  is  highly  important; 
and  this  may  be  done  by  forcing  wedges  between  the  jaws  on 


770  MAXILLA    INFERIOR. 

each  side.  Cork  is  often  used  for  such  wedge,  or  tlie  dilatable 
double-lever  before  mentioned  is  a  convenient  instrument,  which 
the  patient  can  use  after  some  instruction  by  the  surgeon.  The 
dilating  appliance  is  more  safely  used  between  the  upj)er  and 
lower  bicuspids  and  molars  than  between  the  incisors,  for  the 
Latter  would  be  in  danger  of  being  broken.  And  along  with 
these  instrumental  means,  the  muscles  and  soft  j)arts  which  are 
contracted  should  be  subjected  to  frequent  massage. 

Luxation  of  the  Maxilla  Inferior. — The  anatomical  cliaracter- 
istics  of  the  temporo-maxillary  joint  require  some  mention  as  an 
aid  to  a  proper  understanding  of  the  luxation  of  the  lower  jaw. 

The  head  of  the  condyle  is  separated  from  the  temporal  bone, 
in  the  glenoid  fossa  of  which  it  is  lodged,  by  an  inter-articular 
cartilage,  and  the  inclo.sing  parts  around  are  so  loose  that  the 
head  of  the  condyle  and  the  cartilage  can  leave  their  cavity  and 
glide  forwards  upon  the  articular  eminence,  which  lies  in  front 
of  the  glenoid  cavity.  Such  movement  occurs  when  the  mouth 
is  widely  opened  or  the  jaw  is  advanced  forwards.  The  constant 
pressure  of  the  liead  of  the  condyle,  aided  by  the  occasional 
pressure  on  the  cartilage,  tends  to  perforate  the  central  part  of 
the  cartilage.  The  lines  which  represent  the  long  axis  of  the 
masseter  muscle  and  that  of  the  ramus  of  the  lower  jaw  are 
normally  nearly  parallel,  but  when  the  jaw  is  luxated,  these  lines 
approach  above,  and  finally  touch  or  cross  each  other.  This  is 
explained  by  the  fact  that  in  luxation  the  condyle  moves  for- 
wards and,  as  it  does  so,  the  angle  below  moves  backwards;  and 
hence,  when  the  condyle  is  thus  displaced,  the  contracting  mas- 
seter holds  both  condyle  and  angle  in  their  abnormal  sites. 

Celsus  says  the  maxilla  may  be  luxated  forwards,  and  this 
may  be  unilateral  or  bilateral.  If  the  luxation  be  unilateral, 
the  jaw  and  chin  are  inclined  to  the  other  side;  the  teeth  below 
do  not  correspond  to  their  fellows  above,  but  the  canines  lie 
underneath  the  incisors.  If  luxation  be  on  both  sides,  the  entire 
chin  is  advanced  and  depressed,  and  the  lower  teeth  project 
beyond  the  superior  ones.  The  temporal  muscles  appear  tense. 
This  description  is  so  nearly  like  that  of  Hippocrates  that  it  is 
probable  that  Celsus  copied  it  from  Hippocrates.  And  Hippoc- 
rates says  further  concerning  the  accident  that  it  is  rare  and 
occurs  during  gaping. 

Hippocrates  greatly  overrates  the  gravit}'-  of  dislocation  of 
the  lower  jaw;  he  says  that  if  double  luxation  is  not  reduced 
immediately,  the  patient  commonly  succumbs  within  ten  days 


LUXATION    OF    THE    MAXILLA    IXFERIOR.  771 

to  a  continued  fever  or  a  grave  coma.  And  to  guard  against 
Ijeril  Celsus  directs  bleeding.  These  statements  do  not  corre- 
spond with  modern  observation,  and  are  surprising  since  the 
ancients  rarely  err  in  their  account  of  fractures. 

In  a  dissertation  on  maxillary  luxation  Beaugrand  states  that 
its  true  pathology  was  announced  by  Fabricius  d'Aquapendente, 
Monro,  and  Delpech.  Delpech  says  that  from  the  inside  of  the 
mouth  one  can  feel  and  verify  the  position  of  the  coronoid  pro- 
cess, which  in  luxation  rests  against  the  makir  prominence,  and 
he  thinks  that  the  lodgment  at  that  point  is  the  chief  impedi- 
ment to  reduction. 

According  to  Xelaton,  in  luxation  of  the  inferior  maxilla,  the 
anterior  wall  of  the  articular  capsule  must  be  opened,  and  the 
condyle  advanced  C[uite  beyond  the  anterior  root  of  the  zygoma; 
the  external  lateral  ligament  is  rendered  tense,  though  not  sev- 
ered; and  the  coronoid  process  may  be  thrust  into  the  teniporal 
muscle,  and  thus  reduction  is  rendered  difficult.  The  coronoid 
process  can  reach  and  rest  against  the  malar  bone. 

Steinlein,  of  St.  Gall,  Switzerland,  in  1852,  studied  the  mecli- 
anism  of  the  luxation  of  the  inferior  maxilla:  he  finds  that  in 
the  beginning  of  the  opening  of  the  mouth,  the  lower  jaw  repre- 
sents a  one-armed  lever,  of  which  the  fulcrum  is  tlie  summit 
of  the  condyloid  process;  but  as  the  condyle  advances  forwards 
in  the  movement,  the  axis  of  motion  is  shifted  downwards,  to 
near  the  insertion  of  the  external  lateral  ligament;  finally,  the 
condyle  reaches  and  stands  on  the  summit  of  the  articular  tuber- 
cle, when  the  center  of  movement  will  descend  downwards  on  the 
ramus,  towards  the  angle.  As  soon  as  the  jaw  has  reached  this 
position,  all  the  masticatory  muscles,  except  the  external  ptery- 
goid, will  unite  in  drawing  the  condyle  beyond  the  articular 
tubercle;  and  if  the  submaxillary  muscles  add  their  quota  to 
those  above,  then  the  articular  capsule  will  be  ruptured,  and  lux- 
ation becomes  complete. 

Hippocrates  says  that  luxation  arises  from  separation  of  the 
lower  jaw  from  the  upper  one,  combined  with  lateral  deviation. 

It  has  occurred  during  violent  gaping,  laughing,  vomiting, 
and  other  acts  in  which  the  mouth  is  opened  greatly.  Luxation 
has  occurred  during  an  epileptic  convulsion;  also  in  pulling  teeth, 
and  in  forcing  open  the  jaws  to  use  the  stomach  tube  for  alimen- 
tation or  vomiting.  The  writer  has  known  a  case  caused  by  the 
dentist;  and  another  arose  during  efforts  made  by  himself  to 
introduce  the  stomach  tube  in  a  case  of  attempted  suicide.     It 


7T-> 


iMAXILLA    INFERIOR. 


occurs  oftener  in  women,  in  consequence  of  the  greater  laxity  of 
the  peri-articuhir  structures  in  the  female. 

The  suhject  of  luxated  inferior  maxilla  i^resents  himself  to 
the  surgeon  "with  open  mouth,  separated  jaws,  with  advanced 
chin,  and  this  is  deviated  to  one  side,  if  the   luxation  is  uni- 


FiGURE  91.    Luxation  of  Inferior  Maxilla. 

lateral.  The  appearance  is  shown  in  Figure  91.  The  saliva 
is  escaping  from  the  mouth;  articulate  speech  is  interfered  with, 
since  the  labial  and  mute  sounds  cannot  be  properly  formed. 
Though  the  patient  suffers  but  little  pain,  his  usual  ignorance 
of  the  nature  of  his  case  often  gives  him  an  expression  of  fear 
and  anxiety.  The  writer  has  a  vivid  recollection  of  a  man 
who  called  on  him  for  treatment  at  a  late  hour  of  night.  In 
answer  to  the  question,  what  ailed  him,  after  repeated  efforts 
to  make  himself  comprehended,  he  was  understood  to  say,  "I 
have  got  the  lockjaw."  And,  literally,  this  was  no  mean  descrip- 
tion of  his  condition. 

The  prognosis  is  favorable;  for,  if  seen  early,  no  luxation  is 
more  easily  reduced;  and  even  if  seen  some  weeks  after  the  acci- 
dent, it  is  commonly  reducible.  The  dislocation  may  recur;  and 
such  recurrence,  if  often  repeated,  ultimately  takes  place  so  easily, 
that  by  a  voluntary  act  the  patient  may  luxate  and  again  reduce 
the  jaw.  Such  a  patient  the  writer  knows,  who  within  a  few  sec- 
onds could  luxate  and  again  return  the  condyle  to  place.  This 
disposition  to  dislocation  might  be  avoided  by  proper  care  after 


LUXATION    OF    THE    MAXILLA    INFERIOR.  '773 

the  primary  accident.  Anchylosis  may  occur  where  tlie  joint 
remains  unreduced  for  a  long  period;  this,  however,  has  rarely 
been  observed. 

Treatment. — The  plan  of  Hippocrates  has  served  as  a  model 
for  succeeding  generations  of  surgeons.  One  assistant  grasps  and 
steadies  the  head;  the  surgeon  grasps  with  his  fingers  the  jaw, 
both  on  the  inside  and  the  outside,  near  the  chin;  meantime, 
while  the  patient  is  opening  the  mouth  as  wide  as  possible,  the 
surgeon,  for  some  time,  moves  the  jaw;  and  as  he  does  this,  he 
directs  the  patient  to  move  the  jaw,  and  yield  as  much  as  possi- 
ble to  the  movements  tliat  are  being  made;  then  to  reduce,  three 
movements  are  to  be  made;  lift  the  jaw  towards  its  normal 
place,  push  it  backwards,  and  close  the  mouth.  After  reduction, 
retain  the  chin  in  place  by  a  bandage. 

Celsus,  following  this  plan  soniewhat,  advises  the  surgeon  to 
insert  his  thumbs  into  the  patient's  mouth  after  he  has  wrapped 
them  in  linen  so  that  they  cannot  slip  (he  might  rather  have  said 
to  avoid  being  bitten);  with  the  remaining  fingers  on  the  outside, 
the  jaw  is  strongly  grasped,  and  the  work  of  reduction  is  then 
finished  by  shaking  and  depressing  the  chin,  and  then  forcing 
the  maxilla  into  its  site.  Feed  the  patient  on  a  liquid  diet,  and 
let  him  not  speak. 

Fabricius  d'Aquapendente  advises  to  do  the  work  so  simi- 
larly to  the  above  that  it  is  probable  he  was  a  close  student  and 
follower  of  the  Fathers  of  Medicine;  nevertheless,  Fabricius  has 
the  fame  of  originating  the  plan  of  reduction  now  in  use. 

The  surgeon  usually  finds  the  luxated  jaw  tightly  fixed  in  the 
abnormal  situation;  to  overcome  this,  press  the  jaw  downwards 
and  move  it,  as  the  old  authorities  direct;  this  is  more  applicable 
where  some  time  has  elapsed  since  the  luxation,  and  adhesions 
between  surfaces  have  formed.  Most  authorities  use  a  similar 
method  of  reduction  in  both  unilateral  and  bilateral  luxation. 
Leo,  however,  directs  in  bilateral  luxation  to  reduce  each  condyle 
separately;  he  claims  that  in  this  way  the  reduction  is  more  eas- 
ily accomplished. 

Maisonneuve,  from  experimental  luxation  of  the  inferior 
maxilla  in  the  cadaver,  found  that  the  articular  capsule  is  not 
torn;  nor  did  he  find  the  coronoid  process  entangled  in  the  tem- 
poral muscle  as  taught  by  Nelaton.  After  luxation,  even  if  the 
coronoid  process  were  exsected,  he  did  not  find  the  reduction 
any  easier.  His  plan  of  reduction  was  to  gently  depress  the 
chin,  and  with  the  thumbs  to  press  the  coronoid  process  back- 


774  MAXILLA    INFERIOR. 

wards.  Maisonucuve's  plan  of  reducing  does  not  differ  materially 
from  that  of  Nelaton,  who  introduced  his  thumbs  within  tlie 
mouth,  and  placing  them  against  the  ascending  portion  of  the 
jaw,  he  pressed  this  backwards  and  downwards.  And  the  work 
can  be  done  without  an  assistant,  if  tlie  surgeon  standing  behind 
supports  the  patient's  head,  wliile  he  makes  pressure  on  the  jaw 
on  the  outside. 

If  seen  early,  as  the  writer  has  learned  from  experience,  noth- 
ing is  easier  than  to  reduce  the  luxated  maxilla:  let  the  patient 
rest  his  head  against  a  wall  while  the  surgeon,  standing  in  front, 
grasps  the  cliin  with  one  hand,  and  pushes  backwards,  while 
with  the  other,  seizing  the  angles  of  the  jaw,  he  pulls  downwards 
and  backwards.  Should  he  fail  to  replace  in  this  way,  let  a 
couple  of  pieces  of  w'ood,  wedge-shaped  at  one  end,  be  introduced 
between  the  upper  and  low^er  jaws  behind:  and  with  these  small 
levers  the  lower  molars  can  be  separated  from  the  upi)er  ones; 
and  while  the  jaw  is  being  depressed  behind  on  one  or  both  sides, 
according  as  the  luxation  is  unilateral  or  bilateral,  let  the  chin 
be  uplifted  in  front,  and  likewise  pressed  backwards;  or  briefly 
put,  to  reduce,  first  depress  the  jaw  behind,  and  then  lift  the  chin 
and  press  it  backwards. 

In  case  the  patient  has  no  molar  teeth,  or  has  teeth  so  decayed 
that  they  cannot  bear  pressure,  then  the  wedge-sha})ed  levers 
must  be  wrapped  in  cloth,  or  elastic  rubber  material,  so  that  the 
gums  will  not  be  injured.  , 

Where  the  luxation  has  existed  for  some  time,  reduction 
becomes  more  difficult;  yet  it  has  been  effected  after  luxation  has 
continued  for  three  or  four  months;  Gosselin  and  Michon  reduced 
one  which  had  existed  for  one  hundred  and  thirty  days.  In  such 
cases,  the  peri-articular  structures  have  contracted  and  shrunken, 
similarly  to  what  occurs  in  cases  of  unreduced  luxation  elsewhere, 
and  this  becomes  an  obstinate  hindrance  to  reduction;  hence,  the 
first  step  in  such  cases  is  to  break  up  adliesions  and  lengthen  the 
contracted  tissues.  This  may  be  accomplished,  in  some  degree, 
by  depression  and  lateral  movements  of  the  chin. 

Complex  contrivances  have  been  devised  to  effect  reduction; 
such  instruments  consist,  in  the  main,  of  two  blades  which  are 
separable  by  a  screw  which  traverses  them;  and  tlie  whole  is  to  be 
fastened  to  the  head  by  horizontal  and  vertical  straps.  Instead 
of  this  complicated  instrument,  the  work  of  separating  the  poste- 
rior teeth  and  depressing  the  ja,w  behind  can  easily  be  done  with 
the  double  lever  before  mentioned:  one  or  two  should  be  u.sed. 


FRACTURE    OF    THE    LOWER   JAW.  775 

according  as  luxation  is  on  one  or  both  sides.  The  ends  of  these 
should  be  padded.  That  reduction  has  been  effected  will  be 
shown  by  the  condyloid  eminence  appearing  in  its  usual  place 
before  the  tragus;  the  chin  is  uplifted,  the  mouth  can  be  closed, 
and  the  teeth  of  the  lower  jaw  correspond  to  those  in  the  upper 
one. 

The  luxation  can  easily  recur,  and  care  must  be  taken  to  pre- 
vent this:  viz.,  the  mouth  must  not  be  widely  opened;  and  this 
precaution  is  the  more  needful  after  a  luxation  of  long  standing. 
To  lessen  the  mobility  of  the  jaw,  the  food  should  be  taken  in 
liquid  form. 

Fracture  of  the  Lower  Jaw. — The  fracture  of  the  lower  jaw, 
according  to  Despres,  is  one  of  the  most  infrequent  in  the  general 
list  of  fractures;  yet  Emmert,  on  the  contrary,  says  that  it  is  of 
frequent  occurrence.  These  statements  show  that  surgeons  may 
differ  greatly  in  their  experience.  Gurlt,  in  a  collection  of  two 
hundred  and  seventy-four  fractures  of  the  bones  of  the  face, 
reports  that  one  hundred  and  fifty-three  were  those  of  the  lower 
jaw. 

The  lower  jaw  can  be  broken  at  any  point;  and  the  causal 
agency  may  act  directly  or  indirectly. 

Direct  violence,  as  the  kick  of  a  horse,  a  blow  with  a  club  or 
fist,  a  stone  hurled  with  the  hand,  or  a  gun-shot  missile,  may 
cause  such  fracture.  Or  the  violence  may  act  indirectly,  as  by 
pressure;  and  then  the  two  branches  of  the  maxillary  arch  may 
be  forced  towards  each  other,  and  cause  fracture  in  front  of,  or 
behind,  the  point  of  pressure.  Or  fracture  may  arise  from  widen- 
ing of  the  arch;  and  this  can  occur  from  pressure  on  the  chin;  or 
from  explosion  of  powder  within  the  mouth,  the  arch  may  be 
widened  and  fracture  ensue.  In  experimental  fracture  of  the 
lower  jaw,  Linhart  found  that  the  site  of  fracture,  when  the 
branches  are  forcibly  pulled  apart,  is  not  at  the  symphysis,  but 
at  some  distance  behind  that  point. 

For  consideration,  fractures  of  the  inferior  maxilla  may  be 
divided  into  those  of  the  body,  the  ramus  and  the  condyle. 

Fracture  of  the  body  may  be  incomplete;  or  it  may  be  com- 
plete, with  integrity  of  the  soft  parts;  or  complete  with  laceration 
of  the  soft  parts;  .and  lastly,  there  may  be  multiple  fracture. 

Incomplete  fracture  involves  but  a  portion  of  the  bone;  the 
outer  plate  alone  may  be  broken.  This  fracture  often  escapes 
observation;  it  was  studied  by  Cluzeau,  who  finds  that  it  is  situ- 
ated oftener  on  the  inner  side  of  the  jaw. 


77C  MAXILLA    INFKEIOK. 

Incomplete  fracture  of  the  jaw  may  concc-ni  ihe  alveolar  i)ro- 
cess  alone;  and  this  commonly  arises  from  a  blow  or  fall  against 
the  teeth;  and  it  is  indicated  by  the  displaced  teeth:  one  or  more 
teeth  having  forsaken  their  normal  position.  Such  fractured 
portion,  though  attached  to  the  jaw,  is  movable.  Some  swelling 
soon  appears  in  the  soft  tissues  at  the  site  of  injury. 

In  complete  fracture  of  the  body,  when  tiie  soft  parts  are 
intact,  the  broken  surface  may  be  smooth,  notched,  or  otherwise 
irregular.  The  line  of  fracture,  when  studied  in  reference  to  the 
vertical  height  of  the  body,  may  be  nearly  perpendicular;  or  it 
may  run  obliquely:  and  in  the  latter  case,  its  usual  direction  is  from 
above  downwards  and  backwards.  And  when  examined  in  ref- 
erence to  the  thickness  of  the  bone,  it  commonly  runs  from  before 
backwards  and  inwards.  There  may  be  but  slight  displacement; 
and  sometimes,  impaction  exists.  This  com}>lete  fracture  without 
perforation  of  the  soft  parts  occurs  oftenest  near  the  canine  teeth; 
more  rarely  near  the  symphysis.  Less  solidity  of  the  bone 
near  the  canine  teeth  favors  fracture  there.  Fracture  at  the  sym- 
physis, mentioned  by  Hippocrates,  has  been  denied  by  modern 
surgeons:  but  more  careful  observation  has  placed  on  record  a 
number  of  cases.  The  indications  of  com])lete  submucous  frac- 
ture are  swelling,  and  sometimes  ecchymosis  at  the  site  of  frac- 
ture; the  subject  is  able  to  use  his  jaw  in  masticating,  yet  there 
may  be  perceived  a  grating  or  crepitating  sound  at  the  j)oint  of 
fracture.  Also,  if  the  patient  open  his  mouth,  and  the  jaw  be 
grasped  and  vertical  ti'action  be  made  on  the  chin,  then  motion 
■will  be  perceived  at  the  site  of  fracture.  Such  movement  must 
be  cautiously  made,  lest  the  submucous  injury  be  converted  into 
an  open  wound. 

In  case  the  fracture  be  one  in  which  the  soft  parts  have  been 
opened,  the  visible  breach  of  the  bone  renders  the  diagnosis  easy; 
and  by  manual  movement  of  the  part,  crepitation  and  gaping  of 
the  fragments  are  produced.  In  case  the  fracture  is  single,  there 
will  be  but  slight  displacement  of  the  broken  ends,  but  when 
the  fracture  is  multiple,  there  is  often  considerable  loss  of  normal 
form.  If  the  fracture  be  on  both  sides  of  the  chin,  for  example. 
in  the  vicinity  of  the  canine  or  bicuspid  teeth,  then  the  front 
portion  of  the  broken  arch  may  be  displaced  by  the  sublingual 
muscles,  while  the  posterior  fragments  can  be  drawn  upwards  by 
the  masseter  muscles.  Again,  if  the  double  fracture  comprise  a 
segment  of  the  side  of  the  jaw,  this  can  be  displaced  upwards  or 
downwards  according  to  its  site.     In  case  of  multiple  fracture,  the 


FRACTURE    OF    THE    LOWER    JAW.  777 

site  is  commoul}^  near  the  canine  tooth.  The  opening  through 
the  soft  parts  permits  the  escape  of  blood  from,  the  artery  wliich 
is  opened  in  the  dental  canal,  a  bleeding  rarely  great  in  quantity. 

Whether  the  fracture  be  single  or  multiple,  the  line  of  the 
breach  often  lies  between  the  roots  of  two  teeth,  so  that  the  latter 
remain  fixed  in  the  jaw;  or  the  alveolar  cavity  may  be  impli- 
cated so  that  one  or  more  teeth  become  loosened,  and  then,  or 
later,  they  fall  out. 

Fracture  may  have  its  site  in  the  ramus,  or  in  the  condyloid 
or  coronoid  process.  The  fracture  of  the  ramus  is  most  often  sit- 
uated near  its  angle;  and  whether  there,  or  higher  upwards,  it 
would  be  revealed  by  crepitation  and  pain  in  the  upward  and  down- 
ward movement  of  the  jaw.  Bimanual  pressure,  made  by  the 
hands  grasping  the  two  branches,  would  detect  mobility,  and 
probably  crepitation,  in  the  broken  side.  But  little  displacement 
attends  single  fracture  of  the  ramus :  but  if  multiple,  the  displace- 
ment is  determined  by  the  direction  of  the  muscular  movement 
acting  on  the  detached  fragment. 

Fracture  of  the  condyle  is  seldom  seen  as  an  isolated  injury; 
there  is  usually  cotemporaneous  fracture  of  the  body  of  the  jaw, 
and  usually,  both  condyles  share. in  the  complicated  injury.  As 
signs  of  such  fracture  are  swelling  over  the  injured  point,  and 
]3ain  when  the  jaw  is  opened  and  an  attempt  to  masticate  is 
made;  and  in  this  movement  crepitation  might  be  detected. 
Bleeding  from  the  ear  is  often  present. 

The  coronoid  process  is  so  safely  entrenched  behind  the 
zygoma,  that  its  fracture  is  usually  accompanied  by  a  fracture  of 
the  zygomatic  arch.  Great  violence  directly  applied  is  necessary 
to  produce  it.  The  injury  would  be  indicated  by  pain  when  the 
teeth  were  clenched:  a  movement  calling  into  action  the  tempo- 
ral muscle,  and  consecjuently,  traction  on  the  fragment. 

A  causal  agency  of  fracture  of  the  lower  jaw  is  the  bullet: 
and  when  gunshot  wounds  of  the  face  are  enumerated,  those  of  the 
inferior  maxilla  are  the  most  frequent.  Such  fracture  may  be 
single  or  multiple,  and  at  any  point.  The  missile  may  enter  in 
front  or  at  the  side;  or  having  entered  at  a  point  distant  from 
the  jaw,  by  direct  or  meandering  route,  the  ball  may  reach  and 
break  the  lower  jaw.  A  small  ball  may  enter  and  lodge  in  the 
body  of  the  jaw.  The  ball  may  be  spent,  and  cause  a  mere  fis- 
sure, the  simplest  form  of  incomplete  fracture;  or  if  the  impact 
be  of  greater  force,  a  comminuted  fracture  may  result.  A  small 
ball,  moving  with  great  velocity,  may  pass  through  the  jaw  with- 
50 


778  MAXILLA    INFERIOR. 

out  severing  it  in  its  entirety:  the  injury  being  limited  to  the 
shot  canal,  without  furtlier  fracture.  Such  simple  injury  would 
speedily  heal;  but  whore  tlie  fracture  is  comminuted,  and  tlie 
soft  parts  are  extensively  lacerated,  recovery  is  tedious:  necrosis 
and  repair  by  callus  consume  many  months  in  reaching  their 
conclusion. 

The  diagnosis  of  the  entrance  and  exit  points  of  the  missile  is 
determined  by  the  principles  which  have  been  considered  in 
the  chapter,  which  treats  of  gunshot  wounds  of  the  cranial  wall. 

The  fracture  of  the  lower  jaw  is  often  accompanied  by  other 
injury;  for  example,  the  violence  from  a  fall  upon  the  chin,  is 
but  partially  expended  in  a  fracture  of  the  jaw:  a  part  of  the 
force  is  transmitted  to  the  base  of  the  skull.  And  thence  have 
arisen  fracture  of  the  petrous  portion  of  the  temjioral  bone,  injury 
of  the  middle  ear,  and  concussion  of  the  brain. 

The  prognosis  depends  on  the  condition  of  the  soft  parts  cov- 
ering the  fracture:  if  opened  to  the  broken  bone,  the  manage- 
ment is  difficult,  the  recovery  tedious,  and,  sometimes,  doubtful. 
In  fact,  Richet,  from  a  study  of  the  fracture,  finds  that  it  may 
end  fatally.  In  a  collection  of  tliirtj^-six  cases  six  terminated 
fatally.  Even  cases  which  primarily  seemed  simple,  at  a  later 
time  developed  grave  complications.  And  this  is  in  accord  with 
the  author's  experience.  For  not  rarely,  suppuration  has 
appeared  at  some  point  below,  and  near  the  place  of  fracture, 
and  an  abscess  of  greater  or  less  volume  has  arisen,  and  seriously 
interfered  with  recovery.  Besides  the  loss  of  teeth,  which  is  a 
frequent  occurrence,  necrosis  of  the  broken  ends,  and  more  often 
of  a  separated  fragment,  leads  to  non-union,  which  renders  the 
jaw  nearly  functionless.  In  case  the  soft  parts  are  so  open  within 
the  mouth  as  to  lead  to  tedious  suppuration  and  the  escape  of 
septic  materials,  which  pass  down  the  throat,  then  the  general 
health  may  seriou.sly  suffer  through  pulmonary  implication  or 
perverted  nutrition.  Heath  observes  that  from  such  fracture 
haemorrhage  has  arisen,  so  severe  as  to  demand  compression  of  the 
carotid  artery  to  arrest  the  escaping  blood.  Hence  it  is  apparent 
that  compound  fracture  of  the  lower  jaw,  though  seemingly 
holding  a  subordinate  place  among  fractures,  may,  in  its  final 
consequences,  assume  proportions  of  ominous  gravity. 

Treatment. — Hippocrates,  and  after  him  Celsus,  treated  this 
fracture  by  both  intra-oral  and  external  appliance.  "Where  frac- 
ture existed  without  displacement,  they  depended  chiefly  on  liga- 
ture of  the  teeth:  and  in  this  work,  not  one  alone,  but  several 


FRACTURE    OF    THE    LOWER    JAW.  779 

teeth  on  each  side  of  the  fracture  were  included  and  held  by  gold 
wire;  or  still  better,  with  linen  thread  carefully  tied.  If  displace- 
ment exists,  after  careful  coaptation,  tie  the  teeth  together,  and 
then  apply  a  contentive  apparatus  on  the  outside.  Hippocrates, 
though  writing  in  the  incomparable  Greek,  modestly  admits 
the  difficulty  of  clearly  describing  surgical  dressing:  "The 
reader  must  draw  an  idea  as  best  he  can  from  what  has  been 
written."  The  external  appliance  consisted  of  two  strips  of  Car- 
thaginian leather,  about  two  inches  broad.  The  one  piece  is  fas- 
tened on  the  jaw  by  means  of  adhesive  glue,  beginning  a  short 
distance  from  the  fracture,  and  it  passes  thence,  including  the 
chin,  along  the  opposite  cheek  to  the  summit  of  the  head:  the 
other  strip  is  similarly  glued  to  the  jaw  at  a  point  near  the  frac- 
ture, and  is  carried  upwards  over  the  head,  and  there  the  two 
thongs  are  tied.  The  patient  must  lie  on  the  injured  side.  The 
Hi^jpocratic  method  contains  the  germinal  elements  of  traction 
and  counter-traction  which  enter  so  largely  into  the  modern 
treatment  of  fractured  limbs.  Fixation  by  means  of  wire  includ- 
ing the  teeth,  so  much  in  vogue  in  antiquity,  usually  loosens  the 
included  teeth:  hence  this  contentive  means  is  rarely  resorted 
to  by  the  modern  surgeon:  in  only  exceptional  cases  has  the 
writer  used  it:  cases  of  obstinate  displacement,  in  which  two  or 
more  teeth,  on  each  side  of  the  fracture,  could  be  included  in  the 
ligature;  thus  distributing  and  lessening  the  ill  effect  of  the  pres- 
sure. 

The  treatment  of  the  fractured  lower  jaw  demands  that  atten- 
tion be  given  to  the  following  points:  (1)  Where  displacement 
exists,  the  fragments  must  be  accurately  adjusted,  (2)  Immobili- 
zation and  retention  of  the  fragment  in  this  corrected  position. 
(3)  Frequent  cleansing  and  disinfection  of  the  oral  cavity. 

1.  Where  displacement  exists,  adjustment  is  easily  accom- 
plished by  grasping  the  two  sides  with  the  hands  and  lifting  the 
two  ends  into  normal  place;  and  even  if  there  be  an  isolated 
fragment,  this  is  easily  restored  to  jDlace.  Evidence  that  the 
fragments  have  been  restored  to  normal  site  will  be  furnished  by 
a  return  of  the  teeth  to  their  accustomed  ranks  and  natural  rela- 
tion. Such  teeth  must  not  deviate  inwards  nor  outwards,  nor 
stand  higher  nor  lower  than  their  fellows  in  the  adjacent  broken 
end. 

2.  Restitution  to  normal  form  is  rarely  difficult;  yet  mainte- 
nance of  that  form  is  difficult:  so  difficult  that  innumerable 
means  have  been  devised  to  accomplish  it.     As  in  pertussis  the 


780  MAXILLA    INFEUIOR. 

countless  remedies  proposed  denote  their  fallibility  and  impo- 
tence, so  the  many  appliances  which  have  been  devised  for  tlie 
treatment  of  the  broken  maxilla  have  similar  signification;  the 
perfect  device  has  not  yet  been  invented. 

Cases  in  which  there  is  no  displacement  of  the  broken  ends 
recover  through  the  use  of  any  contcntive  appliance;  any  form 
of  splint,  which,  slipper  like,  includes  the  chin,  and  which  is 
retained  in  place  by  a  bandage  including  chin,  cheeks  and  sum- 
mit of  the  head,  will  secure  satisfactory  immobilization  of  the 
fracture;  and  especially  is  this  the  case  where  the  soft  parts  sur- 
rounding the  bone  are  unopened.  In  case  the  soft  parts  are 
opened,  a  disagreeable  complication  that  frequently  arises  in  the 
course  of  the  treatment  is  abscess,  which  may  appear  at  some 
point  near  or  subjacent  to  the  fracture.  From  the  writer's  expe- 
rience, it  is  an  exception  when  such  abscess  does  not  occur;  and 
occurring,  it  interferes  with  the  contentive  dressing. 

In  case  of  compound  multiple  fracture,  in  which  the  broken 
jaw  consists  of  two  or  more  fragments,  exact  maintenance  of  these 
parts  in  normal  site  is  extremely  difficult;  in  the  writer's  exten- 
sive ex{ierience  in  fractures,  he  has  encountered  no  problem  of 
which  the  solution  has  been  more  embarrassing,  and,  in  its 
solution,  the  author  will  next  brief!}''  notice  the  methods  whicli 
have  been  employed. 

The  appliances  may  be  divided  into  two  classes:  those 
which  are  applied  externally,  and  those  placed  within  the  mouth; 
and  in  many  cases,  internal  and  external  appliances  are  com- 
bined. And  in  the  use  of  whatsoever  kind  of  appliance,  coapta- 
tion must  precede  and  accompany  the  contentive  means. 

To  pass  in  review  the  numerous  splints  which  have  been 
devised  for  outward  fixation,  would  be  a  tiresome  enumeration 
of  mechanical  appliances,  many  of  whicli.  happily  for  the  j)atient, 
repose  in  the  lumber  room  of  oblivion  alongside  of  similar  ones 
which  have  preceded  them. 

A  simple  splint,  the  invention  of  which  is  attributed  to  Dr. 
Physic,  may  be  made  of  an  oblong  piece  of  felt  or  thick  paste- 
board, fifteen  inches  long,  and  five  inches  broad;  let  this  be  cut 
at  its  middle,  half  way  through  its  breadth;  thus  prepared,  it  can 
be  folded  so  that  the  cut  edges  overlap  each  other.  Thus  is 
formed  a  slipper-like  trough  in  which  the  chin  can  rest,  and  the 
whole  be  retained  in  position  by  a  bandage  which  passes  under 
the  jaw  and  obliquely  over  the  summit  of  the  head,  and  horizon- 
tallv  around  the  chin  and  behind  the  neck.     The  horizontal  and 


FRACTURE    OF    THE    LOWER    JAW.  781 

oblique  turns  of  the  bandage  cross  each  other  like  a  figure  of 
eight,  on  each  side,  near  the  angle  of  the  mouth.  Since  the 
bandage  is  easily  deranged,  a  safer  plan  is  to  fix  such  a. splint  in 
place  by  means  of  a  starch  or  gypsum  bandage;  and  to  jjrotect 
the  ears  and  hair,  there  must  be  placed  beneath  such  bandage  a 
stratum  of  cotton  wadding.  Instead  of  the  felt  or  pasteboard, 
the  writer  has  used  gutta  percha ;  of  this  a  strip  of  suitable  size 
immersed  in  hot  water,  can  be  molded  to  the  fractured  jaw,  and 
retained  in  place  by  one  of  the  bandages  just  mentioned. 

Adjuvant  appliances  placed  on  the  inside  of  the  mouth  are  of 
three  forms:  one  applied  on  the  inside  of  the  jaw,  between  the 
jaw  and  the  tongue;  another,  which  rests  on  the  outer  side;  and  a 
third  one  which,  trough-like,  rests  on  and  includes  the  lower 
teeth;  and  sometimes  it  is  hollow  both  below  and  above,  and 
then  it  receives  the  upper  and  the  lower  teeth.  The  material 
from  which  these  intra-oral  splints  is  best  made  is  gutta  percha, 
or  vulcanized  India  rubber.  The  last  kind  is  the  most  efficient 
one,  and  this  may  be  so  constructed  as  to  include  the  upper  and 
lower  teeth,  and  also  ensheathe  the  lower  alveolar  process  on  the 
inside  and  outside.  In  its  construction  and  application,  the 
services  of  an  expert  dentist  will  materially  aid  the  surgeon. 
Should  a  tooth  be  absent  above  or  below,  a  corresponding  open- 
ing should  be  made  through  the  splint,  through  which  a  tube 
can  pass  for  alimentation  and  irrigation.  Such  intra-oral  appli- 
ance must  be  combined  with  an  external  bandage. 

During  the  use  of  such  a  splint,  the  oral  cavity  must  be 
washed  out  several  times  daily;  and  always  after  the  use  of  food. 
AVithout  this  precaution,  the  cavity  becomes  a  pest-hole  of  foul- 
ness. Such  disinfecting  irrigants  are  mint-water,  alcoholized 
water,  or  chlorine  water  well  diluted.  Such  fluid  may  be  intro- 
duced through  a  tube  which  is  carried  through  an  interval 
between  teeth,  or  through  the  space  behind  the  molar  teeth.  As 
instrument  for  the  irrigation,  a  flexible  catheter  and  a  flexible 
syringe  may  be  employed  ;  the  latter  can  readily  be  converted 
into  a  siphon. 

The  patient  must  be  nourished  with  liquid  food,  such  as 
milk,  soups  and  similar  articles  of  diet.  This  can  be  introduced 
by  means  of  a  tube  passed  between  or  behind  the  teeth,  as  just 
mentioned. 

In  ordinary  cases,  consolidation  occurs  within  a  period  of 
thirty  days;  but  in  cases  in  which  there  is  laceration  of  the  con- 
taining soft  parts,  with  multiple  or  comminuted  fracture  entail- 


782  MAXILLA    INFERIOR. 

iiig  recurrent  displacement,  the  injury  will  require  two  or  three 
mouths  for  recovery. 

In  cases  in  which  the  attendant  displacement  is  irrepressible 
by  any  of  the  appliances  mentioned,  as  an  additional  aid  metallic 
suture  may  be  resorted  to.  This  method  was  first  done  by  Bau- 
dens  in  1840;  it  has  since  been  done  and  recommended  by  E.  S. 
Cooper,  Kinloch,  Giordano  and  others.  The  writer  has  resorted 
to  it,  with  satisfactory  result,  in  a  few  cases.  Such  suture  is  done 
within  the  mouth,  by  means  of  silver  wire  passed  through  holes 
drilled  through  the  fractured  ends,  and  knotted  between  the 
cheek  or  lips  and  the  jaw.  And,  sometimes,  even  this  fails  to 
maintain  accurate  coaptation;  and  then  a  splint  and  bandages 
must  also  be  used.  Despite  the  treatment  here  described, 
recovery  is  sometimes  attended  with  irregularity  of  form;  one  of 
the  fractured  ends  is  higher  than  the  other;  yet,  in  such  cases,  the 
future  work  of  mastication  will  tend  to  reduce  the  teeth  to  a  com- 
mon level,  and  in  time  greatly  lessen  the  deformity. 

Finally,  should  non-union  result,  through  loss*  of  osseous 
structure  or  other  cause,  then  the  fractured  ends  should  be 
exposed  by  dissection,  and,  after  removal  of  the  intermediate 
fibrous  tissue,  the  ends  should  be  iinited  by  metallic  suture,  and 
the  case  treated  as  a  compound  fracture. 


CHAPTER  XXIV. 


FACIAL    NEURALGIA. 


As  synonyms  of  facial  neuralgia  are  the  names  prosopalgia 
and  tic  douloureux;  the  latter  is  of  Gallic  extraction.  Tic  signi- 
fies a  convulsive  movement  and  refers  to  a  spasmodic  movement 
of  the  affected  parts,  which  is  often  present. 

Neuralgia  literally  signifies  a  painful  nerve;  and  thus  defined 
the  term  has  relations  with  the  entirety  of  Pathology,  for  the 
most  important  element  in  every  Pathos  is  the  subjective  one  of 
pain.  And  pain  is  the  result  of  some  textural  change  in  nervous 
material  of  which  the  normal  function  is  common  sensation;  and 
to  awaken  this,  some  Nosos  or  irritant  is  needed.  And  such  irritant 
may  be  located  within,  contiguous  to,  or  near  to  the  nerve  which 
responds  by  pain,  and  which,  though  so  clearly  appreciable  by 
the  subjective  sufferer,  may  not  be  so  to  the  objective  observer; 
since  in  many  cases,  no  structural  change  is  determinable  by 
chemical  or  physical  test,  or  by  means  of  touch  or  any  special 
sense.  Macroscopy  failing  in  the  search,  has  committed  the 
quest  to  microscopy,  which,  though  aided  by  its  lens  of  immer- 
sion, has  caught  no  glimpse  of  the  fugitive  pain.  It  is  probable 
that  such  search  will  not  always  be  in  vain;  and  that  along  with 
the  metrical  appliances  which  have  been  introduced  as  aids  in 
scientific  exploration,  an  sesthiometer  and  odynometer  will 
sometime  be  included.  In  such  search  and  research,  cognizance 
must  be  taken  of  the  molecular  changes  which  occur  from  the 
action  of  pain-annulling  and  pain-awakening  agents:  a  most 
abstruse  problem,  in  the  solution  of  which  Chemistry  must  lend 
the  patient  investigator  its  single  elements,  and  also  its  com- 
pounds of  double,  triple  and  variously  and  diversely  multiplied 
elements;  and  Physics,  with  its  thermal,  electric,  luminous  and 
spectroscopic  means,  will  be  invoked  to  contribute  its  quota  of 
assistants. 

Uspensky,  who  has  labored  on  this  question,  refers  \)QXn  to 

(783) 


78-i  FACIAL    NEURALGIA. 

the  contact  with  nerve-tissue  of  the  elements  of  disintegration, 
which  arc  acid  in  nature;  and  that  in  the  normal,  or  what  may 
be  styled  tlie  anodyne  condition  of  the  tissues,  the  acid  compounds 
excreted  are  neutralized  by  the  alkaline  nuiterials  of  the  lymph 
and  blood.  Uspensky  offers  a  few  facts  in  confirmation  of  this 
theory.  The  writer  would  suggest  that  this  notion  might  be 
amended  by  adding  the  work  of  integration  to  that  of  disintegra- 
tion; or  that  in  both  progressive  and  regressive  tissue-metamor- 
phosis, materials  may  arise  which  by  contact  with  sensory  nerves 
can  awaken  pain.  Inasmuch  as  neuralgia  is  relieved  by  numer- 
ous plans  of  treatment,  some  differing  much  from  each  other,  it 
is  possible  that  the  chemical  tlieory,  here  mentioned,  may  either 
directly  or  suggestivel}^  indicate  one  pathway  leading  to  relief. 

The  face  is  the  usual  site  of  neuralgia;  and  a  portion  or  the 
whole  of  the  trifacial  nerve  may  be  affected  there.  While  this 
nerve,  by  virtue  of  its  isolated  function,  furnishes  watchful 
guardianship  of  the  special  sensory  apparatus,  it  is  also  the 
medium  of  intense  suffering  when  it  is  the  object  of  some  morbific 
agency.  The  seventh  or  facial  pair  of  nerves,  stands  to  the 
fifth  pair  as  its  motor  correlate,  since  its  function,  as  commonly 
stated,  is  exclusively  that  of  motion.  Yet  it  is  probable,  that  a 
few  fibers  pass  from  the  fifth  to  the  seventh  pair,  in  the  parotidean 
region;  and  to  such  inter-communication  is  due  the  simultaneous 
advent  of  pain  and  motion  as  the  predominating  symptoms  of 
facial  neuralgia. 

Stromeyer  claims  that  every  manifestation  of  normal  sensa- 
tion has  its  correlate  of  motion;  and  that  a  painful  sensation  has 
its  motor  reflex,  so  sudden  as  to  be  of  the  nature  of  spasm : 
examples  of  which  are  seen  in  anal,  vesical,  and  palpebral  spasm 
awakened  by  some  sensory  irritant. 

A  characteristic  of  facial  neuralgia  is  the  exquisite  acuteness 
of  the  pain  which  is  present;  also  its  inconstant  nature.  There 
are  also  points  where  the  pain  predominates;  this  fact  was  pointed 
out  by  Valleix;  though  reasoned  away  by  writers  wlio  have  no 
clinical  communion  with  the  disease,  yet  the  subject  of  them  can- 
not so  readily  do  so. 

The  trifacial  nerve  beyond  the  Casserian  ganglion  divides 
into  three  branches,  which  diverge,  and  at  their  ending,  each 
one  has  its  isolated  and  individual  peripheral  field;  and  these 
fields  have  different  bounding  lines  of  demarcation,  which  are  as 
follows:  The  district  of  innervation  of  the  ophthalmic  or  superior 
branch   has  tlie  foUowintr   boundaries:   draw  a   line  from  the 


FACIAL    NEURALGIA.  785 

cranial  vertex  across  the  anterior  portion  of  the  temporal  plane  to 
the  ouier  angle  of  the  eye;  then  pass  inwards  through  the  palpe- 
bral sHt  to  the  inner  angle  of  the  eye;  thence  run  clown  the  nose 
to  its  point;  and  thence  upwards  to  the  point  of  departure.  In 
this  field  is  also  included  the  mucous  lining  of  the  superior  and 
middle  turbinated  bones,  and  the  other  intra-nasal  structures 
corresponding  to,  and  on  a  level  with,  these  bones. 

The  superior  maxillary  branch  is  distributed  to  a  field 
bounded  as  follows:  Draw  a  line  from  the  outer  angle  of  the  eye 
to  the  angle  of  the  mouth;  and  in  this  field  is  included  within 
the  nose  the  inferior  turbinated  bones,  and  that  portion  of  the 
intra-nasal  structure  which  is  not  concerned  in  olfaction.  This 
branch  also  supplies  the  teeth  and  the  soft  parts  investing  the 
upper  jaw  and  hard  palate;  also,  the  soft  palate  and  tlie  clioanse 
have  nervous  sup[)ly  through  the  superior  maxillary  nerve. 

The  inferior  branch  of  the  trifacial  supplies  innervation  to 
structures  W'hich  lie  behind  and  below  the  districts  supplied  by 
the  ophthalmic  and  the  superior  maxillary  branches;  behind, 
this  field  is  bounded  by  a  line  drawn  from  the  vertex  of  the  head 
to  the  ear,  and  thence  to  the  chin.  Within  the  mouth  it  supplies 
filaments  to  the  floor  of  the  mouth  and  to  the  entire  tongue, 
except  that  portion  of  the  base  which  lies  behind  the  papillee 
.circumvallatse.  It  likewise  supplies  the  lower  teeth,  the  inferior 
alveolar  process,  the  lower  lip,  and  the  mucous  lining  of  the 
cheeks  within  the  buccal  cavity. 

The  i^rimary  terminal  branches  of  the  three  divisions  of  the 
fifth  nerve  appear  on  the  face  in  a  vertical  line,  at  the  following 
points:  the  supra-orbital  and  infra-orbital  foramina,  and  the 
mental  foramen.  The  doctrine  that  neuralgic  pain  is  especially 
concentrated  at  these  points,  as  before  stated,  is  contested  by  some 
authorities;  the  writer,  however,  within  his  professional  experi- 
ence, has  seen  cases  in  which  the  pain  greatly  predominated  at 
one  of  these  sites:  especially,  at  the  mental  foramen;  and  the 
diagnosis  thence  drawn  that  the  inferior  maxillary  branch  was 
the  site  of  the  affection  was  confirmed  by  the  relief  which  followed 
neurectomy  of  that  nerve. 

A  knowledge  of  this  abstruse  disease  can  best  be  gained  by  a 
^eviewof  the  literature  on  the  subject,  which  the  author  will  now 
compendiously  present. 

In  1849,  Xeucourt,  writing  on  this  subject,  divides  facial 
neuralgia  into  two  groups:  that  which  arises  from  pressure,, 
and  that  which  originates  spontaneously,  in  wdiich  only  some 


7SG  FACIAL    NEUKALCJIA. 

remote  morbid  condition  can  be  referred  to  as  causal  agency. 
Valleix  espouses  tiie  opinion  of  indirect  or  spontaneous  origin. 
As  alleged  causes  of  tbe  indirect  class  are  cborea,  hysteria,  rheu- 
matism, plethora,  tlie  use  of  narcotics,  heat,  cold,  miasma,  syphilis 
and  gonorrha-a.  Some  of  these  so-called  causes,  when  examined, 
vanish  to  verbiage:  names  in  which  the  realist  seeks  in  vain  fur 
substance.  Neuralgia  may  arise  from  pressure  on  the  dental 
nerves  through  disease  of  the  teeth;  and  in  such  cases,  some 
swelling  can  be  found  nround  the  tooth:  or  the  alveolus  in  the 
aged  can  undergo  a  change,  in  which  through  slow  atrophy, 
sometimes  accompanied  by  i)ain,  the  root  of  the  tooth  is  dis- 
placed. Neuralgia  can  occur  in  all  portions  of  the  face;  and  it  is 
often  situated  in  small  S])Ots,  in  which  one  can  only  find  filaments 
derived  from  the  facial  nerve.  It  may  disappear  from  one  part 
of  the  face  and  appear  at  another. 

Trousseau  finds  in  the  species  of  neuralgia,  which  the  French 
name  tic  douloureux,  an  epileptiform  element;  in  this  form, 
pain  can  be  awakened  by  some  slight  cause:  for  exami)le,  from 
a  touch,  eating,  speaking,  and  even  from  an  emotional  thought. 
The  attacks  of  pain  are  of  extreme  vehemence,  and  are  attended 
by  a  trembling  or  spasmodic  movement  of  the  neighboring  facial 
muscles.     This  form  is  difficult  to  cure. 

In  1859,  Schramm  wrote  on  facial  neuralgia,  in  an  essay  in 
which  were  detailed  the  observations  of  one  hundred  and  ninety- 
five  cases.  In  two-thirds  of  the  cases,  the  affection  was  in  the 
inferior  branch  of  the  trifacial.  It  was  often  associated  with 
intermittent  fever;  and  then  the  attacks  occurred  periodically, 
assuming  in  some  a  quotidian,  and  in  others  a  tertian  form. 
The  periodical  form,  though  seemingly  cured,  commonly  recurs. 
In  other  cases,  the  disease  "was  coincident  with  dental  disease, 
rheumatic  or  gastric  trouble.  The  u.se  of  quinine,  arsenic  and 
iron  cured  many  of  these  cases. 

Oppenheimer  finds  facial  neuralgia  to  depend  on  affection  of 
tlie  nasal  mucous  niembrane;  or  it  may  arise  from  nasal  polyp; 
such  cases  were  only  cured  through  treatment  of  the  nose. 

Salter,  of  Guy's  Hospital,  published,  in  1S6S,  his  investigations 
of  facial  neuralgia.  He  finds  that  it  may  arise  directly  or  reflexly ; 
it  may  appear  in  the  supra-orbital  or  infra-orbital  nerves,  and  the 
pain  be  felt  in  the  temple,  eye  and  near  the  summit  of  the  head. 
Where  the  trouble  has  continued  long,  the  skin  is  red  and  hot. 
Facial  neuralgia  may  extend  and  implicate  some  portion  of  the 
cervical  and  brachial  plexuses  of  nerves;  and  thus  the  arm  may 


FACIAL    XEURALGIA.  787 

lose  its  muscular  power.  Salter  infers  a  connection  between 
the  trigeminus  and  the  nerves  of  the  arm,  especially  with  the 
ulnar  nerve.  Spasm  and  weakness  of  the  affected  muscles 
are  present.  As  initial  causes  of  such  nervous  trouble  are  caries 
of  the  teeth,  exposure  of  the  dental  pulp,  periostitis,  exostosis, 
and  crowding  of  tlie  teeth  against  each  other.  Salter  cites  numer- 
ous cases  which  support  his  doctrine;  cases  in  which,  concurrent 
with  the  neuralgia,  were  kindred  affections,  as  trismus,  torticollis, 
tetanus,  epilepsy,  neuralgia  in  the  neck  and  arm,  amaurosis  and 
deafness.  Salter  places  much  stress  on  dental  disease;  he  con- 
siders this  the  direct  or  indirect  cause  of  neuralgia. 

Anstie,  of  London,  in  1868,  wrote  on  facial  neuralgia.  Char- 
acteristic conditions  of  the  affection  are  the  tendency  to  exacer- 
bate and  intermit,  and  the  disproportion  between  the  violence  of 
the  jjain  and  the  accompanying  constitutional  disturbance.  The 
pain  is  often  confined  to  one  branch  of  a  nerve-trunk,  and  is 
usually  unilateral;  or  if  it  be  on  both  sides,  then  the  pain  mav 
be  symmetrical;  or  there  may  be  a  greater  number  of  branches 
affected  on  one  side  of  the  face  than  on  the  other.  And  the  pain 
is  influenced  by  the  condition  of  the  body;  for  example,  it  is 
intensified  by  fatigue  or  other  depressing  causes.  Under  the 
head  of  aetiology,  Anstie  enumerates  the  following  as  causal 
agencies  or  influences:  heredity,  malaria,  and  prolonged  centrif- 
ugal or  centripetal  irritation.  As  examples  of  such  irritation 
are  excessive  use  of  the  eye,  pus  in  the  vicinity  of  a  nerve,  or 
syphilitic  growths  encroaching  on  the  nerve.  Again,  syphilis 
may  cause  a  morbid  change  in  the  central  nervous  system.  In 
cases  in  which  the  neuralgia  has  continued  long,  or  has  a 
high  degree  of  intensity,  then  there  may  be  present  the  points 
of  pain,  noticed  by  A^alleix.  There  may  be  secondary  implica- 
tion of  the  secretor}'-  glands  of  the  mouth  and  face;  or  through 
action  on  the  vaso-motor  nerves,  there  may  be  altered  nutrition 
of  the  parts,  and,  as  result,  muscular  paresis,  and  some  degree 
of  anassthesia.  Anstie  is  certain  that  there  is  a  morbid  change 
in  the  sensory  nerve,  or  in  the  centre  whence  it  arises;  and 
finally,  an  interstitial  atrophy  may  occur  in  the  nerve,  ending 
in  degeneration  of  its  tissue. 

Benedict,  in  1871,  advises  the  division  of  neuralgia  into  two 
classes:  in  one  the  paroxysms  may  have  a  continuous  character, 
though  the  intensity  may  rise  and  fall ;  and  a  second  class  in 
which  the  attacks  are  not  continuous,  but  consist  of  momen- 
tary attacks.     The  second  class  comprises  the  excentric  neuralgic 


788  FACIAL    NEURALGIA. 

affections.  If  trij^eminus  neuralgia  be  thus  divided,  tic  doulou- 
reux belongs  to  the  second  class.  In  tic  douloureux,  temperature 
is  increased,  the  facial  muscles  are  tense,  and  there  is  cedema  of 
the  superjacent  surface.  Benedict  has  observed  in  long-standing 
facial  neuralgia  a  dilatation  of  the  carotid  artery;  and  in  some  cases 
the  vessel  was  widened  and  tortuous.  The  dilatation  seemed  coin- 
cident with  (edema  and  increased  temperature.  In  some  cases  the 
vessel  seemed  narrow;  and  in  such  the  parts  sui)[)lied  by  it  were 
cyanosed.  Benedict  does  not  refer  the  widening  of  the  carotid  to 
obstruction  of  the  peripheral  capillaries;  but  he  deems  it  due  to 
widening  of  these  capillaries,  and  an  extension  centrally  of  this 
widening.  And  this  dilated  condition  of  the  carotid  I'urnishes  a 
therapeutic  hint  for  ligation  of  the  vessel. 

According  to  the  writer's  experience,  facial  neuralgia  occurs 
much  oftener  in  the  male  than  in  the  female,  and  this  is  dueto 
the  more  frequent  ex|)Osure  of  the  former  to  cold,  or  traumatic 
violence. 

The  prognosis  is  doubtful.  The  physician  may  promise  relief 
by  internal  medication;  and  this  relief,  in  most  cases,  is  only 
partial  and  transient;  exceptionally,  it  may  be  permanent.  The 
phy.sician  has  numerous  medicines  which  he  may  successfully 
tr3%  until  he  finds  the  one  suited  to  the  case;  and  along  with  the 
remedies  used  to  cure  the  neuralgia,  anodyne  and  anaesthetic 
means  should  be  used  to  lessen  the  pain.  A  review  of  these 
means  will  now  follow. 

As  internal  remedies,  the  following  may  be  tried:  quinine  in 
full  doses;  and  its  action  will  be  improved  by  combining  the 
quinine  with  morphia.  Atropine  may  be  given  in  doses  of  one- 
sixtieth  of  a  grain,  conjointly  with  morphia.  Additional  reme- 
dies are  guarana  combined  with  gelsemium,  strychnia,  aconite, 
colcliicum  and  cimicifuga.  Pfaff  recommends  the  internal  use 
of  turpentine.  Fowler's  solution  of  arsenic  and  carbonate  of  iron 
may  be  tried.  Phenacetin  in  ten-grain  doses,  or  antipyrin  in 
similar  doses,  relieves  some  cases.  Bromide  of  zinc,  bromide  of 
caffein,  and  the  oxide  of  zinc  have  given  relief.  In  syphilitic 
subjects  mercury  in  some  form  should  first  be  given,  and  after- 
wards the  mercury  should  be  given  with  iodide  of  potassium. 
The  writer  saw  an  inveterate  facial  neuralgia  yield  to  an  atro- 
cious ptyalism  :  the  cure  cost  the  patient  his  teeth. 

Along  with  internal  medicines,  or  subsequent  to  their  unsuc- 
cessful trial,  local  remedies  may  be  used  on  the  sites  of  pain,  or 
injected  into  the  affected  structures;  of  such  means  the  following 


FACIAL    NEURALGIA.  789 

may  be  tried.  The  external  application  to  the  painful  part  of 
Daphne  mezereum  has  relieved;  likewise  inunction  with  an 
ointment  composed  of  morphia  and  extract  of  Belladonna  has 
given  relief.  Lusanna  used  by  inunction  a  similar  compound, 
viz.,  three  grains  of  atropine  to  half  an  ounce  of  adeps;  and  of 
this  he  rubbed  in  a  small  portion,  which  contained  about  one- 
eighth  of  a  grain  of  atropine.  Lombard  advises  the  inhalation 
of  fumes  arising  from  burning  a  mixture  of  opium,  benzoin  and 
sugar. 

Morphia  and  cocaine  may  be  used  parenchymatously ;  of  either 
one,  from  three  to  six  minims  of  a  five  per  cent  solution  may  be 
injected  into  the  painful  part;  and  such  injection  would  contain, 
in  the  one  case,  one-eighth  of  a  grain,  and  in  the  other,  one-fourth 
of  a  grain. 

As  additional  remedial  agencies  the  follow^ing  have  been  used 
and  commended.  In  1792,  Parry  advised  the  comjDression  of  the 
carotid  artery  to  relieve  facial  neuralgia.  Later  this  treatment 
was  commended  by  Liston,  Preston,  Trousseau,  Malapart  and 
Tlirck.  Li  1850,  Tiirck  published  the  account  of  cases  of  facial 
neuralgia  which  were  thus  successfully  treated.  Tiirck's  expla- 
nation of  the  mode  of  action  of  compression  is,  that  it  acts 
through  pressure  made  on  branches  of  the  vagus  and  sympathetic 
nerves.  As  far  as  possible,  the  internal  jugular  vein  should  be 
avoided. 

Desterne  claims  to  have  cured  facial  neuralgia  by  touching 
the  membrana  tympani. 

Electricity  has  been  found  beneficial  in  some  cases;  Benedict, 
especially,  commends  galvano-therapy:  he  applies  the  positive 
pole  to  the  mastoid  process,  and  passes  the  current  upwards. 
Many  others  have  verified  the  efficacy  of  the  electrical  treatment. 

Andre  reports  the  cure  of  obstinate  cases  of  facial  neuralgia 
by  surrounding  the  site  of  the  pain  with  fenestrated  adhesive 
plaster,  and  then  cauterizing  the  exposed  part  with  caustic  potash : 
and  as  soon  as  the  eschar  was  detached,  the  cauterization  was 
repeated  until  the  bone  was  reached. 

In  1850,  Malgaigne  reported  the  successful  treatment  of  facial 
neuralgia,  as  well  as  neuralgia  elsewhere,  by  cauterization  of  the 
external  ear:  in  eighteen  cases  thus  treated,  six  were  cured. 
According  to  the  author's  experience,  such  cauterization  applied 
directly  on  the  seat  of  pain,  often  gives  relief.  As  thermal  agents 
which  he  has  tried  are  the  galvanic  or  simple  thermal  cautery, 
burning  sealing  wax  and  melted  diachylon. 


790  FACIAL    NEURALGIA. 

Numerous  operative  procedures  have  been  resorted  to  for  relief 
of  facial  neuralgia;  prominent  among  these  are  ligation  of  the 
afferent  artery,  the  simple  division  of  the  nerve,  and  exsection  of 
a  portion  of  the  affected  nerve. 

Liiiation  of  the  carotid  arterv,  bv  which  the  blood  is  diverted 
from  the  affected  structures,  has  been  done  in  a  few  ca>es,  and 
relief  thus  obtained.  In  a  case  of  violent  facial  neuralgia,  seen 
by  the  writer  in  18G6,  the  common  caroti'd  was  tied,  and  the 
neuralgia  permanently  relieved.  No  cerebral  or  nervous  compli- 
cation followed  tlie  woi'k,  but,  as  this  sometimes  occurs,  it  would 
be  prudent  to  reserve  this  radical  procedure  for  last  resort:  medi- 
cation, cauterization  and  electricity  having  failed,  should  it  then 
be  found  that  compression  of  the  carotid  artery  removes  the  pain, 
as  a  means  of  permanent  compression,  the  writer  would  ligate 
the  carotid  in  the  lower  part  of  its  course. 

Some  of  the  primary  essays  in  neurectomy  were  made  by  an 
ignorant  tinker,  who  lived  in  an  obscure  corner  of  Paris.  Richet 
records  that  this  man,  for  thirty  year.s,  had  relieved  patients  of 
dental  neuralgia  by  a  cut  on  the  side  of  the  face  near  the  ear. 
Richet,  who  did  not  disdain  to  learn  from  so  humble  a  source, 
learned  and  performed  his  operation,  which  was  done  as  follows: 
introduce  a  bistoury  through  the  skin  between  the  tragus  and 
the  condyle  of  the  lower  jaw,  to  the  depth  of  three  lines.  In  such 
an  incision,  the  knife  would  meet  the  auriculo-temporal  branch 
of  the  inferior  maxillary  nerve;  and  the  temporary  relief  which 
often  follows  such  incision  must  be  due  to  incision  of  this  nerve. 

Neurectomy  often  falls  short  of  its  purpose :  the  relief  from  it 
is  but  temporary;  the  divided  nerve  reunites,  and  the  neuralgia 
returns:  and  to  render  the  work  more  effective,  neurectomy,  or 
removal  of  a  portion  of  the  trunk  of  the  nerve,  has  superseded 
simple  division. 

The  pioneer  in  the  work  of  neurectomy  was  Bdrard,  who,  in 
1830,  announced  an  operation  of  this  kind  ;  and  he  was  followed 
by  Roux,  who,  in  1854,  reported  numerous  neurectomies.  This 
work  of  Roux  is  reviewed  by  Beau,  who,  finding  that  many  of 
the  operations  had  not  resulted  satisfactorily,  refers  tlie  failure  to 
the  fact  that  in  the  resection  too  small  a  portion  of  the  nerve 
had  been  excised.  To  guard  against  reunion  of  the  ends  of  the 
severed  nerve,  Beau  advises  that  a  section  of  it,  an  inch  and  a 
half  long,  should  be  removed  from  the  trunk  of  the  affected  nerve; 
and  he  approves  of  the  counsel  of  Malgaigne  and  others  to 
remove  the  nerve  as  deep  as  possible. 


FACIAL    NEURALGIA.  701 

In  a  dissertation  published  in  1858,  Schuh  offered  some  general 
notions  concerning  facial  neuralgia  and  neurectomy ;  and  he  like- 
wise indicated  the  routes  by  which  the  branches  of  the  trifacial 
can  be  reached  for  their  division. 

Schuh  claims  that  the  operation  is  not  dangerous,,  and  that 
some  relief,  if  not  a  perfect  cure,  is  always  obtained  by  it.  It  is 
difficult  to  locate  the  site  of  a  pseudoplasm,  which  by  pressure  is 
the  causal  agenc}^  If  the  cause  be  deep,  the  j^ain  radiates  periph- 
erally; but  if  the  cause  be  more  external,  the  pain  pursues 
a  central  course.  Pressure,  friction  and-  muscular  movements 
aid  in  determining  the  chief  site  of  pain. 

In  the  sections  of  the  excised  nerve  which  Schuh  examined 
microscopically,  he  failed  to  discover  any  structural  changes:  yet 
he  found  in  the  sheath  of  the  nerve  neoplasms  and  osseous 
changes,  wdiich  he  regarded  as  causes  of  the  neuralgia. 

The  following  indications  are  given  by  Schuh  for  the  opera- 
tion, viz.:  where  the  neuralgia  depends  on  a  superficial  scar; 
where  it  becomes  chronic,  very  intense,  and  medicines  fail  to 
relieve.  It  should  be  done,  also,  in  cases  in  which  but  one  sensi- 
tive branch,  or  but  few  branches  of  one  trunk  are  affected,  and 
the  latter  is  anatomically  accessible.  To  decide  that  a  nerve  is 
really  affected,  there  must  be  a  fixed  point  of  pain  in  the  struc- 
tures supplied  by  the  nerve;  and  also  a  point  whence  the  pain 
radiates.  And  even  in  cases  in  which  such  point  of  pain  was 
absent,  neurectomy  gave  relief  for  some  months. 

To  operate  on  the  frontal  and  supra-trochlear  nerves,  Schuh 
incises  along  the  supra-orbital  margin  to  the  bone:  the  perios- 
teum is  then  reflected  downwards,  and  the  eye  pushed  down- 
wards. The  frontal  nerve  will  be  perceived  glistening  through 
the  reflected  periosteum:  divide  it  as  far  backwards  as  possible, 
and  remove  a  section  of  the  nerve.  Through  the  same  cut  the. 
supra-trochlear  nerve  can  be  found  and  divided. 

To  resect  the  infra-orbital  nerve  make  an  incision  along  the 
lower  edge  of  the  orbit,  and,  entering  the  orbit,  lift  up  the  eye 
with  a  spatula,  and  then  sever  the  nerve  as  far  back  as  possible 
in  its  canal.  This  division  is  done  with  scissors,  and  both 
artery  and  nerve  are  severed.  In  this  division,  the  instrument 
should  not  enter  the  antrum.  Next,  reflect  the  soft  parts  down- 
wards, until  the  infra-orbital  foramen  is  found;  and  when  the 
nerve  is  seen,  draw  it  out  from  the  canal,  and  cut  off  the  part 
withdraw^n.  Should  a  portion  of  bone  be  found  encroaching  on 
th-e  nerve,  the  bone  should  be  exsected;  and  in  this  work  care 


702  FACIAL  nj:lkalgia. 

must  be  taken  not  to  let  any  fragments  of  Ijone  drop  into  tlie 
antrum. 

Schuh  reached  the  subcutaneous  mala)  through  a  cut  by  which 
the  outer  lialf  of  the  floor  of  the  orbit  is  opened,  and  the  nerve  being 
found  there  is  divided  as  far  back  as  possible.  To  reach  the  poste- 
rior branches  of  tlie  superior  maxillary,  let  the  mouth  be  elongated 
laterally,  so  that  the  tuberosity  of  the  upper  jaw  can  be  reached, 
and  its  mucous  membrane  divided  and  so  turned  aside  tliat  the 
nervous  filaments  which  lie  there  can  be  reached  and  severed. 
The  division  of  the  nerve  is  best  done  with  a  chisel.  In  two  cases 
Schuh  destroyed  the  nerves  with  a  hot  iron. 

Tlie  temporal  nerve  can  be  reached  througli  a  vertical  cut  in 
front  of  the  tragus,  and  being  separated  from  the  artery,  the  nerve 
may  be  divided. 

Schuh  sought  the  lingual  nerve  b}'  a  cut  in  the  floor  of  the 
mouth,  made  near  the  posterior  teeth  ;  this  route  for  finding  the 
nerve  is  less  mutilating  than  that  of  lloser,  who  by  incision, 
elongated  laterally  the  commissure  of  the  mouth.  Michel 
divides  the  lingual  nerve  through  a  cut  in  the  floor  of  the 
mouth,  next  to  the  molar  teeth;  and  as  aid  in  the  operation,  the 
tongue  was  drawn  outwards  towards  the  other  side. 

Paravicini  sought  and  reached  the  inferior  dental  nerve 
through  an  incision  in  the  back  of  the  mouth,  in  which  he 
pierced  and  opened  the  internal  pterygoid  muscle;  through  this 
opening  he  forced  his  finger  and  found  the  dental  foramen  and 
the  nerve  entering  it;  from  the  nerve  thus  found,  a  section  was 
cut  out.     Some  bleeding  accompanied  the  operation. 

Bratsch,  in  1863,  reported  ninety-eight  cases  of  neurectomy 
done  for  the  relief  of  neuralgia;  these  operations  were  mostly 
j^erformed  by  Nussbaum  of  Munich.  Of  these  operations,  almost 
an  average  of  six  were  done  on  the  same  person,  so  that  the 
actual  number  of  patients  treated  was  about  sixteen.  Almost  all 
of  the  branches  of  tlie  trifacial  were  o})erated  on.  The  occipital 
was  also  divided. 

The  general  result  obtained  by  these  operations  was  a  favor- 
able one;  and  the  fact  that  rela})se  ensued  in  several  of  the 
patients,  Xussbaum  thinks  was  no  objection  to  the  w^ork,  since 
the  patients  always  demanded  to  be  operated  on  again.  The 
relapses  occurred  in  from  six  to  fourteen  months. 

In  several  of  these  cases,  in  which  the  pain  seemed  located  in 
one  branch  of  the  trifacial,  the  division  of  this  branch  did  not 
remove  the  pain  ;  relief  was  only  obtained  by  the  removal  of  all 


FACIAL    NEURALGIA.  793 

three  branches  of  the  trifacial.  And  where  this  radical  exsec- 
tion  failed,  relief  was  finally  obtained  tlirough  the  ligation  of  the 
carotid. 

Roser,  who  has  operated  several  times  for  the  relief  of  facial 
neuralgia,  gives  the  following  directions  for  finding  the  lingual 
nerve.  An  incision  is  made  through  the  cheek  opposite  the  base 
of  the  tongue,  and  through  this  cut  the  tongue  is  reached,  and 
the  nerve,  being  found,  is  exsected  on  the  base  of  the  tongue,  below 
the  insertion  of  the  stylo-glossus  muscle.  For  the  division  of  the 
inferior  dental  nerve,  Roser  divided  the  masseter  muscle,  and 
having  laid  bare  the  ramus  of  the  inferior  maxilla,  a  trephine 
crown  was  placed  on  this  midway  between  the  coronoid  process 
and  the  lower  margin,  of  the  angle  of  the  jaw;  the  outer  por- 
tion of  the  jaw  was  removed,  and  the  nerve,  being  found,  was 
exsected.  Michel  in  a  case  of  neuralgia  seated  near  the  angle  of 
the  mouth,  concluded  that  the  affection  w^as  in  the  buccal  nerve; 
and  this  supposition  was  verified  by  division  of  the  nerve,  which 
was  done  by  a  cut  made  along  the  anterior  border  of  the  masse- 
ter muscle,  when  a  finger  inside  of  the  mouth  uplifted  the  nerve, 
and  brought  it  into  position  for  division. 

An  examination  of  the  jDublished  results  of  several  operators 
reveals  the  fact  that  neurectomy  does  not  always  accomplish  its 
intended  purpose;  for  in  some  of  tlie  patients  the  operation 
has  partially  failed,  and  in  a  few  it  has  been  wholly  unsuccessful. 
A  search  for  the  cause  of  this  has  led  to  the  conclusion  that,  in 
such  cases,  the  nerve  had  not  been  attacked  deeply  enough.  This 
was  the  notion  of  Goux,  of  Strassburg,  who  wrote  on  the  causes  of 
relapse,  and  concluded  that  it  is  due  to  the  causal  agency  exist- 
ing on  the  proximal  side  of  the  site  operated  on;  or  it  may  arise 
from  the  pain  traveling  from  the  branches  of  a  trunk  which  has 
not  been  divided  into  the  branches  of  the  trunk  already  divided. 
In  such  a  case  the  branches  of  the  cut  and  uncut  nerves  anasto- 
mose; that  is,  there  is  propagation  in  a  manner  which  the  writer 
would  denominate  anastomatic  radiation. 

To  insure  success  in  neurectomy,  Goux  recommends  to  divide, 
in  rebellious  cases,  all  the  branches  of  the  trifacial  nerve. 

To  destroy  the  nerve  as  deeply  as  possible,  after  neurectomy,  the 
central  stump  has  been  cauterized  by  some  surgeons  b}"  means  of 
a  heated  wure,  which  was  thrust  into  the  stump.  Such  cauteri- 
zation has  chiefly  been  done  in  the  case  of  neurectomy  of  the 
infra-orbital  nerve. 

In  patients  in  whom  neurectomv,  as  above  described,  failed 
51 


79-1  FACIAL    NEURALGIA. 

to  cure,  indicating  that  the  causal  agency  was  more  deeply 
located,  surgical  enterprise  has  passed  the  boundaries  which  the 
prudent  conservatism  of  the  past  liad  fixed  as  the  Ultima  Thule 
for  the  surgical  exidorer;  and  the  intre})id  feats  here  done  seem 
cognate  to  the  daring  depicted  by  the  classic  Mantuan,  in  whicli 
the  Promethean  race  launched  their  barks  upon  and  crossed  for- 
bidden seas.  Indeed,  by  means  of  the  Promethean  liglit  with 
which  Anatomy  illumines  the  way  of  the  scalpel,  old  boundaries 
have  recoiled,  and  the  surgeon  now  penetrates  to  the  base  of  the 
skull,  and  there  divides  the  middle  and  inferior  branches  of  the 
trigeminus;  and  recently  even  tlie  cranial  w^all  has  been  opened, 
and  the  trifacial  branches  divided  close  to  their  encephalic 
origin. 

In  tlie  work  of  dee[)  extra-cranial  neurectomy,  the  name  of  .J.M. 
Carnochan,  of  New  York,  merits  special  mention.  His  operation, 
done  in  1855,  was  on  tlie  superior  maxillary  nerve,  which  he 
severed  near  the  foramen  rotundum;  and  in  the  operation,  the 
spheno-palatine  ganglion  was  also  excised.  Carnochan  placed 
much  stress  on  the  removal  of  this  ganglion.  The  operation 
began  by  the  formation  of  a  triangular  flap  on  the  cheek,  which 
being  uplifted,  the  front  wall  of  the  antrum  as  well  as  the  infra- 
orbital foramen  were  exposed.  This  wall  was  now  excised  and 
the  antrum  freely  opened.  Afterwards,  the  posterior  wall  was  per- 
forated, so  that  the  spheno-palatine  fossa  was  opened  to  view.  The 
superior  maxillary  nerve  will  there  be  seen  prior  to  its  entering 
the  infra-orbital  foramen ;  and  also  the  spheno-palatine  (Meckel's) 
ganglion.  A  segment  of  this  nerve  together  with  the  ganglion  is 
to  be  excised.  The  pioneer  case  thus  operated  on  was  seen  by  the 
writer  a  few  days  after  the  operation;  also  the  segment  of  nerve 
which  had  been  removed.  The  ganglion  was  unusually  large, 
as  well  as  the  trunk  of  the  nerve.  The  breach  in  the  man's  face 
was  a  great  one:  since  the  work  was  done  previous  to  the  time 
when  the  cosmetic  element  began  to  share  in  the  surgeon's 
operative  work  on  the  face.  The  patient  seemed  delighted  with 
his  mutilation,  since  in  exchange  for  it,  he  was  wholly  freed  from 
his  neuralgic  torture. 

The  operation  of  Carnochan  might  be  so  modified  as  to  avoid 
much  of  the  deformity  which  was  left  by  the  work  :  namely,  the 
anterior  wall  of  the  antrum  might  be  uplifted  in  connection  with 
the  soft  parts,  and  afterwards  replaced. 

The  bold  procedure  of  Carnochan  has  given  his  name  an 
enduring  place  in  operative  surgery.     In  works  on  surgery,  no 


FACIAL    NEURALGIA.  795 

matter  in  what  language  written,  in  the  chapter  upon  neurectomy; 
one  finds  a  mention  of  tliis  operation. 

In  1872,  Woodbury  reported  that  Pancoast,  of  Philadelphia", 
performed  an  operation, somewhat  analogous  to  that  of  Carnochan, 
for  the  relief  of  neuralgia  seated  in  the  inferior  maxillary  nerve. 
This  was  done  as  follows :  A  pedunculated  flap  was  made  over  the 
ramus  of  the  inferior  maxilla;  this  flap  was  detached  above  and 
allowed  to  hang  attached  below.  Thus  he  reached  the  coronoid 
process,  and  resected  the  same;  then  arresting  the  htemorrhage 
by  means  of  Pagliari's  styptic,  he  reached  and  tied  the  internal 
maxillary  artery.  The  next  step  was  to  pluck  out  the  fatty 
tissue,  and  detach  the  external  pterygoid  muscle  from  its  attach- 
ment to  the  sphenoid  bone;  and  finally,  the  foramen  ovale  being 
reached,  exsection  was  made  of  the  inferior  maxillary  nerve. 

Through  the  same  route,  Pancoast  proposed  to  reach  the  fora- 
men rotunduni,  and  then,  having  thrown  a  ligature  around  the 
superior  maxillary  nerve,  pull  it  out  and  excise  a  portion  of  it. 
And  if  one  desired  to  remove  a  large  portion  of  the  nerve,  he 
could  lay  bare  the  infra-orbital  foramen,  and  having  seized  the 
nerve  there,  it  could  be  pulled  out,  and  thus  removed. 

In  exsection  of  the  inferior  maxillary,  at  the  foramen  ovale, 
Pancoast  found  that  the  sense  of  taste  was  lost  on  the  correspond- 
ing side  of  the  tongue. 

The  deforming  mutilation  caused  by  the  operation  of  Pan- 
coast,  and  the  interference  with  mastication  which  it  entails,  are 
serious  objections  to  it.  Nevertheless,  the  pain  of  facial  neural- 
gia is  so  intense,  in  many  cases,  that  the  patient  is  willing  to  be 
quit  of  it  at  any  cost;  yet,  before  undertaking  an  operation  so 
deforming  as  either  of  the  operations  mentioned,  the  surgeon 
should  be  very  certain  in  his  diagnosis  that  the  patient  will  not 
afterwards  have  a  revolting  deformity  added  to  his  uncured  neu- 
ralgia. 

The  undismayed  foot-tread  of  surgical  audacit}^  not  content 
with  reaching  the  cranial  base,  has  recently  overleaped  that  bar- 
rier and  attacked  the  sensory  trunk  of  the  trifacial  near  its  emer- 
gence from  the  pons  Varolii.  Surgical  enterprise  failing  to  sub- 
due the  enemy  by  an  attack  on  the  outworks,  has,  adopting  the 
maxim,  Fledere  si  nequeo  superos,  Acheronta  movebo,  penetrated 
within  the  citadel  of  life.  Diefi'enbach  and  Stromeyer  were  so 
inimical  to  neurectomy  as  done  in  their  time,  that  they  declined 
to  give  a  description  of  the  operation  in  their  works  on  surger}^ ; 
had  they  foreseen  that  the  Casserian  ganglion  some  day  would 


796  FACIAL    NKUllALGIA. 

be  the  objective  aim  of  tlie  excising  instrument,  their  liostility 
would  doubtless  have  swollen  with  a  higher  tide  of  indignation. 

This  operation  is  now  in  the  experimental  and  expectant 
stage,  and  whether  the  hand  of  critical  adjudication,  which  is  now 
adjusting  the  scales,  will  turn  them  towards  the  side  of  acceptance 
or  rejection,  remains  for  decision  in  the  future;  nevertheless,  in 
the  meantime,  one  must  admire  the  boldness  of  the  work  done 
here  by  Rose,  Andrews,  Hartley  and  Horsley. 

Rose  has  lately  published  five  operations  of  this  kind,  done 
for  relief  of  neuralgia  seated  in  the  superior  and  inferior  maxil- 
lary nerves. 

The  fifth  nerve  resembles  a  spinal  nerve  in  this,  that  it  con- 
sists of  a  sensory  and  a  motor  portion;  and  in  the  sensory  por- 
tion, similar  to  the  posterior  root  of  a  spinal  nerve,  there  exists 
the  Casserian  ganglion.  Rose's  operation  removes  this  ganglion, 
which  lies  outside  of  the  dura  mater  on  the  upper  face  of  the 
petrous  bone,  near  the  inner  end  of  the  bone;  and  the  work  is 
done  as  follows:  the  eye  is  closed  by  stitching  the  lids  together,  in 
order  to  protect  this  organ,  which  by  the  operation  will  be  deprived 
of  its  normal  sensibility;  and,  in  consequence  of  this,  the  eye 
will  be  unduly  exposed  to  injury  from  the  contact  of  foreign  bodies. 
Next,  an  inci-sion  is  made  along  the  lower  border  of  the  z3^goma, 
terminating  at  its  posterior  end;  now  this  incision, reaching  only 
through  the  skin,  is  carried  downwards  to  the  angle  of  the  lower 
jaw,  and  then  forward  alongthe  lower  margin  of  the  jaw  to  the  facial 
artery.  The  flap  thus  outlined  is  next  dissected  forwards,  with- 
out wounding  the  facial  artery,  nerve  or  Stenson's  duct.  The 
zygoma  is  next  divided  and  uplifted  and  turned  forwards,  carry- 
ing with  it  the  masseter  muscle.  The  coronoid  process  is  next 
divided  and  shifted  upwards  with  the  attached  temporal  muscle; 
and,  in  later  operations,  Rose  removed  the  process.  The  internal 
maxillary  is  next  ligated,  and  then  divided.  The  external 
pterygoid  muscle  is  then  separated  from  the  sphenoid  bone  and 
the  external  pterygoid  plate.  Next,  a  trephine,  of  hiilf  inch  diam- 
eter, is  made  to  penetrate  the  cranial  wall,  just  anterior  to  and 
outside  of  the  foramen.  The  trunk  of  the  inferior  maxillary 
nerve  served  as  a  guide  in  the  act  of  trephining,  and  likewise  in 
the  subsequent  search  for  the  Casserian  ganglion.  After  Rose  had 
thus  reached  the  ganglion,  he  excised  it  with  curved  hooks,  tak- 
ing care  in  the  division  not  to  open  the  neighboring  cavernous 
sinus.     The  result  of  these  operations  was  satisfactory. 

Horsley  penetrated  yet  deeper,  and  having  removed  a  par.t  of 


FACIAL  NEURALGIA.  797 

the  squamous  portion  of  the  temporal  bone  and  Hfted  up  the 
brain,  he  severed  the  trifacial  at  its  emergence  from  the  pons 
Varolii;  the  patient  died  a  few  hours  afterwards. 

The  temptation  inspired  by  V  envie  des  autres  rivaux  has  led 
surgery  onward  until  it  has  now  reached  the  ultimate  of  opera- 
tive effort,  unless  some  one  ambitious  of  mention  within  the  lists 
of  unjustifiable  temerity,  should  lay  bare  the  medulla  oblongata, 
and,  penetrating  alongside  of  the  vital  point  of  Flourens,  should 
reach  and  destroy  the  nuclear  origin  of  the  trigeminus;  and  the 
bold  hand  who  would  do  this  would  add  another  name  to  ojDera- 
tive  nomenclature,  viz.,  nudearedomy.  But  if  tlie  prudent  voice 
of  conservatism  be  listened  to,  one  hears  the  chiding  remon- 
strance that  there  is  a  limit  beyond  which  it  is  not  allowed,  para- 
phrasing the  words  of  the  Muscovite  potentate,  for  even  surgical 
heroes  to  pass. 

To  conclude  this  chapter  on  facial  neuralgia,  the  writer  will 
add  his  experience  in  reference  to  neurectomy.  In  eight  patients, 
the  subjects  of  facial  neuralgia  which  had  resisted  all  other  plans 
of  treatment,  exsection  of  the  nerve  was  resorted  to ;  in  six  of  the 
cases,  the  superior  maxillary  and  inferior  dental  nerves  were 
operated  on;  and  in  two  patients,  along  with  these  two  nerves, 
the  supra-orbital  nerve  was  also  exsected.  The  subjects  were  all 
males,  and  were  over  forty  years  of  age,  except  one,  who  was 
twenty-five  years  old.  The  neuralgia  was  seated  on  the  right 
side  of  the  face  in  the  majority  of  the  cases. 

The  methods  pursued  in  reaching  the  nerve  were  as  follows: 
To  divide  the  inferior  dental,  a  crescentic  cut  was  made  around 
and  close  to  the  angle  of  the  lower  jaw;  the  insertion  of  the 
external  pterygoid  muscle  was  separated  from  the  jaw  by  means 
of  a  chisel.  Into  the  opening  thus  formed  the  finger  can  be 
passed,  and  the  dental,  foramen  found  by  means  of  the  process 
of  Spix,  a  spike-like  prominence  of  bone  surmounting  the  lower 
edge  of  the  foramen.  The  nerve  and  accompanying  artery  can 
now  be  caught  with  a  blunt  hook  and  torn  asunder.  In  another 
case,  after  a  proper  incision  was  made,  and  the  soft  parts  detached 
on  the  outside,  a  trephine  was  used,  and  the  bone  which  lies 
opposite  the  foramen  was  removed,  and  tlie  nerve  thus  readied 
was  sundered  with  forceps.  This  method  of  approaching  the 
nerve  directly  from  the  outside  is  more  deforming  than  the  pre- 
ceding method,  just  mentioned. 

The  middle  branch  of  the  trifacial  was  reached  by  the  method 
of  Schuh,  Wagner  and  others.     An  incision  is  made  along  the 


79S  FACIAL   NEURALGIA. 

int'ra-orbital  margin,  tlio  inner  end  of  the  cut  terminating 
two  lines  outside  of  the  lachrymal  sack.  This  incision  must 
penetrate  to  the  bone;  and  the  lower  edge  of  the  incision  having 
been  pulled  downwards  so  as  to  display  the  infra-orbital  foramen, 
the  upper  lip  of  the  wound  is  next  lifted  up,  and  the  dissection 
continued  backwards  along  the  floor  of  the  orbit.  This  work  is 
best  done  with  a  blunt  dissector,  by  which  the  periosteum  is 
separated  from  the  orbital  floor;  and  done  thns,  bleeding  will  be 
minimized,  the  peri-orbital  fatty  couch  will  not  be  injured,  and 
can  easily  be  lifted  up;  but  if  the  periosteum  be  fenestrated,  the 
adipose  tissue  will  jiout  through  the  openings.  This  separation  is 
to  be  continued  until  the  inferior  orbital  fissure  is  reached.  The 
infra-orbital  nerve  is  readily  traced  backwards;  for,  with  a  good 
light,  the  nerve  can  be  seen  beneath  the  thin  stratum  of  bone 
which  lies  over  it.  The  orbital  floor  is  so  thin  and  fragile  in  the 
aged  that  it  can  easily  be  broken;  in  fact,  it  was  so  thin  in  one 
case  that  in  the  w^ork  it  was  ruptured,  and  a  fragment  of  sponge 
catching  in  the  breach,  escaped  into  the  antrum.  Knowing  that 
sponge  will  float  in  water,  the  writer  filled  the  cavity  with 
water,  when  the  sponge  floated  to  the  top  and  was  removed.  As 
aids  in  this  work  w'ere  a  small  gilded  spoon,  and  direct  illumina- 
tion with  sunlight.  The  nerve  and  attendant  vessels  were 
caught  at  their  entrance  into  the  canal  with  a  small  pair  of 
forceps,  and  severed  with  scissors  in  front  of  the  forceps.  The 
central  end  held  by  the  forceps  was  pulled  and  twisted,  so  that 
the  nerve  was  acted  on  much  beyond  tlie  point  of  division.  The 
nerve  was  next  seized  at  the  infra-orbital  foramen,  and  the  por- 
tion within  the  canal  was  extracted.  The  wound,  cleansed  with 
alcoholized  water,  was  next  closed  with  fine  wire  sutures;  and  to 
maintain  drainage,  a  small  tube  w^as  used  in  the  early  opera- 
tions; later,  instead  of  this,  a  silken  thread  was  substituted,  and 
answered  equally  well.  Recovery  ensued  with  a  scar,  which,  in 
the  subject  over  fifty  years,  was  almost  imperceptible  after  six 
months. 

The  frontal  nerve  was  reached  through  a  cut  made  along  the 
inner  half  of  the  supra-orbital  margin;  the  nerve  and  artery 
were  seized,  and  divided;  and  on  the  central  end  traction  and 
torsion  were  made.  If  this  cut  be  made  near  the  palpebral  fold 
it  will  afterwards  be  scarcely  visible.  After  section  of  the  infra- 
orbital and  frontal  nerves,  the  wound  was  dressed  with  simple 
cold  water;  and  the  healing  was  rapid,  and  almost  without  sup- 
puration. 


FACIAL    NEURALGIA.  799 

The  operations  done  within  the  orbit  necessitated  some  pres- 
sure on  the  bulb  of  the  eye:  a  circumstance  which  gave  the 
writer  some  anxiety  in  his  early  operations;  in  no  case,  however, 
was  the  eye  injured  by  such  pressure;  nor,  from  the  violence 
done  the  nerves,  has  the  nutrition  of  the  parts,  deprived  of 
sensory  innervation,  been  in  any  way  impaired.  The  results 
obtained  in  the  eight  patients  operated  on  have  been  highly 
favorable  to  neurectomy;  the  most  of  the  patients  were  wholly 
relieved;  and  in  the  few  in  which  there  was  a  recurrence,  the 
pain  was  trivial  in  comparison  with  that  which  existed  prior  to 
the  neurectomy. 


CHAPTER  XXV. 


NECK. 


General  Remarks. — The  neck,  which  connects  the  head  with 
the  trunk,  is  elHptical  transversely,  in  its  lower  portion;  while 
above,  it  is  elliptical  antero-posteriorly.  It  is  isthmus-like,  a 
region  of  transit  for  important  structures  between  the  head  and 
trunk.  These  structures  are  all  important,  and  some  of  them 
necessary  to  existence,  and  tlie  latter  become  the  objects  of 
destructive  attack  from  tlie  hand  of  suicide,  which  desires  to  put 
a  period  to  life;  also  of  the  hand  of  justice  in  its  work  of  punish- 
ing malefaction. 

The  hand  of  the  surgeon  makes  also  frequent  visitations  to 
this  field;  and  in  conservative  etfbrt  and  operative  work,  sur- 
gical art  offers  many  examples  of  humane  intervention :  instances 
of  wdiich  are  correction  of  abnormal  position,  the  combating  of 
stenosis  or  occlusion  of  the  laryngo-tracheal  and  aesophageal 
canals,  and  the  removal  of  growths  which  compress  nerves  con- 
cerned in  respiration,  or  vessels  which  furnish  blood  to  the  head. 
Such  are  the  highly  important  subjects  which  will  be  considered 
in  the  coming  chapters  of  this  work. 

Surgical  Anatomij. — At  the  threshold  of  the  matter,  it  is  neces- 
sary to  notice  topograj)hically  some  of  the  anatomical  components 
of  the  neck,  of  which  an  accurate  knowledge  is  necessary  to  the 
surgeon. 

The  anterior  surface  of  the  neck  is  an  elongated  quadrangle, 
which  is  divided  by  the  larynx  and  trachea  into  two  lateral 
fields,  also  quadrangular  in  outline;  and  each  of  these  lateral 
fields  is  divided  by  the  sterno-cleido-mastoid  muscle  into  two 
somewhat  symmetrical  triangles,  which  may  be  named  the  inner 
and  outer  triangles;  the  base  of  the  outer  one  is  the  clavicle, 
while  the  base  of  the  inner  one  lies  above.  And  the  two  inifer 
ones  combined  may  again  be  conceived  to  be  a  great  median  tri- 
angle, of  which  the  sides,  formed  by  the  sterno-cleiflo-mastoid 
(800) 


SURGICAL    ANATOMY.  801 

muscles,  are  equal;  and-the  apex  of  this  median  triangle  ends  at 
the  manubrium  of  the  sternum.  This  space  contains  nearl}-  all 
the  vitally  important  structures  of  the  neck. 

The  fasciae  in  the  anterior  portion  of  the  neck  should  be 
well  known  to  the  surgeon;  these  are  three  in  number;  the 
superficial,  middle  and  the  deep.  These  fascial  structures  vary 
much  in  strength,  between  extreme  tenuity  and  one  of  strong 
resistance:  sometimes  so  thin  as  scarcely  to  be  demonstrable. 

These  fascial  strata  form  partitions  which  bound  spaces 
within  which  lie  certain  parts  which  enumerated  from  without 
inwards,  are  as  follows:  between  the  skin  and  the  superficial  fas- 
cia lie  the  platysma  myoides,  the  fatty  couch,  and  the  branches 
of  the  superficial  plexus  of  nerves.  The  adipose  layer  varies 
greatly  in  both  infants  and  adults;  it  may  be  absent,  or  amount 
to  an  inch  or  more  in  thickness.  It  is  thicker  in  subjects  in 
whom  the  neck  is  short.  This  fatty  couch  closely  concerns  the 
operation  of  tracheotomy;  when  very  thick,  it  becomes  a  serious 
obstacle  to  the  operator  in  the  work  of  penetrating  to  the 
trachea. 

The  subcutaneous  fascia  extends  laterally  from  the  median  line, 
and  reaching  the  sterno-cleido-mastoid  muscles,  forms  a  sheath  for 
the  latter;  it  passes  thence  to  the  anterior  border  of  the  trapezius 
muscle,  which  it  also  incloses,  by  an  anterior  and  posterior  layer. 
At  the  median  line,  the  superficial  fascia  is  thickened,  and  this  is 
named  the  cervical  linea  alba.  The  fascial  sheath  of  the  sterno- 
cleido-mastoid  is  thinner  below  than  above;  thus,  pus  contained 
within  this  sheath  may  perforate  the  thin  anterior  layer  below 
and  appear  under  the  skin.  The  superficial  fascia  is  attached 
inferiorly  to  the  anterior  margin  of  the  sternum. 

The  middle  layer  of  fascia  starts  above  from  the  hyoid  bone, 
in  common  with  the  superficial  layer;  the  two  soon  separate,  and 
the  middle  passing  below  is  inserted  in  the  periosteum  which 
lines  the  posterior  face  of  the  sternum  and  is  attached  also  to  the 
clavicle.  Thus  a  space  is  left  between  the  superficial  and  middle 
layers,  which  being  thin  above  is  ecjual  to  the  thickness  of  the 
sternum  and  clavicle  below.  The  middle  layer  forms  sheaths  for 
the  sterno-hyoid,  sterno- thyroid  and  omo-hyoid  muscles;  also  a 
sheath  for  the  great  vessels  and  nerves,  and  passing  thence  out- 
wards, it  penetrates  between  the  scalene  muscles,  and  reaching  the 
transverse  processes  of  the  vertebree,  it  is  inserted  into  them. 

In  the  space  between  the  outer  and  middle  cervical  fascia  is  a 
layer  of  lamellated  cellulo-adipose  tissue;  and  in  this  are  con- 


802  XKCK. 

tained  lymphatic  glands.  In  this  space-occurs  the  hroad  phleg- 
mon of  Dupuytren,  a  })hleginonous  abscess  which  may  occupy 
the  greater  i)art  of  the  front  cervical  region.  Pus  contained  in 
this  space  forces  the  anterior  wall  forwards;  and  it  is  prevented 
from  pressing  nnich  on  the  i)arts  behind  by  the  resistant  middle 
laj'er  of  fascia;  and  through  the  ])rotection  given  by  this  firm 
median  fascia,  dyspnoea  and  vascular  obstruction  are  lessened  or 
avoided. 

This  middle  layer,  which  from  its  attachments  may  be  named 
the  hyo-sterno-clavicular  fascia,  has  been  assigned  by  the  anato- 
mist Allan  Burns,  the  very  important  function  of  protecting  the 
trachea  during  the  respiratory  act  of  respiration.  For  a  time 
this  notion  was  generally  accepted;  its  incorrectness  has,  however, 
been  shown  by  the  fact  that  in  immerous  surgical  operations,  in 
which  the  fascia  was  opened,  no  such  collapse  of  the  trachea 
ensued.  In  a  great  number  of  operations  performed  in  this 
region  by  the  author,  the  middle  cervical  fascia  was  divided  with 
no  ill  effect;  and  in  a  few  cases  of  thyreotomy,  the  entirety  of 
the  cervical  portion  of  the  trachea  being  laid  bare,  breathing  was 
not  obstructed.  The  patency  of  the  trachea  is  maintained  by 
its  cartilaginous  walls;  and  only  in  cases  in  which  the  rings  have 
been  softened  and  weakened  by  pressure,  will  the}',  when  laid 
bare,  yield  to  the  atmospheric  pressure. 

The  relation  of  this  middle  fascial  stratum  to  the  carotid 
artery  and  jugular  vein  is  more  important  than  its  connection 
with  the  trachea.  This  fascia,  as  stated,  forms  a  sheath  for  those 
vessels;  and  in  this  is  a  partition  separating  the  artery  from  the 
vein.  The  middle  stratum  forms  ensheathment  for  the  omo- 
hyoid muscle;  and  the  latter,  where  it  lies  on  the  internal  jugular 
vein,  is  tendinous  in  structure;  and  by  virtue  of  this  structure  of 
unchanging  volume,  and  its  fixation  in  the  fascia,  pressure  on  the 
vessel  is  avoided  and  the  venous  circulation  favored.  At  its 
inferior  part  the  fascia  is  closely  adherent  to  the  expanded 
termination  of  the  jugular  vein;  and  since  the  inspiratory  move- 
ment lifts  the  sternum  forwards,  the  effect  is  to  carry  forwards 
the  middle  fascia,  and  to  open  the  vein.  Thus  a  suction-like 
action  is  exerted  on  the  vein,  and  its  blood  is  attracted  towards 
the  heart.  This  suction  is  exerted,  in  some  degree,  on  the  affluent 
veins  which  empty  into  the  internal  jugular  vein;  thus  the  afflux 
of  blood  from  the  head  and  neck  to  the  heart  is  promoted.  The 
advantage  which  the  circulation  derives  from  this  anatomical 
disposition  is  not  shared  by  the  surgeon  in  his  operative  work  on 


SURGICAL    ANATOMY.  803 

the  neck;  for,  if  a  large  vein  be  opened,  the  inspiratory  suction 
may  draw  air  into  tlie  veins,  and  this,  mingling  with  the  blood, 
may  fatally  obstruct  the  circulation. 

Allan  Burns  mentions  a  case  in  which  the  destruction  of  the 
€ervical  fascia  in  a  surgical  operation  was  followed  by  dyspnoea 
after  the  wound  had  healed;  during  inspiration,  the  trachea  was 
compressed,  and  a  hollow  depression  formed  over  the  top  of  the 
sternum.  The  j^atient  breathed  with  effort,  which  was  attended 
by  a  wheezing  sound.  He  suggests  that  relief  might  be  obtained 
in  such  a  condition  by  applying  a  piece  of  leather,  covered  by 
adhesive  plaster,  over  the  affected  part  of  the  neck;  and  to  fix  it 
more  surely,  sealing  wax  dissolved  in  alcohol,  might  be  applied 
to  the  edges  of  the  leather,  which,  thus  fastened,  would  become  a 
substitute  for  the  lost  fascia. 

The  third  layer  of  fascia,  from  its  position,  may  be  named  the 
prsevertebral ;  and  this  stratum  extending  between  the  transverse 
processes,  covers  the  longus  colli  and  other  muscles  situated  in 
front  of  the  cervical  vertebrae;  it  forms  a  sheath  for  the  anterior 
scalene  muscles. 

In  the  third  inter-fascial  space  contained  between  the  middle 
and  deep  fasciae  lie  the  important  structures  of  the  neck,  viz., 
the  carotid  arter}^,  jugular  vein,  the  air-passage,  the  oesoph- 
agus and  the  nerves  which  form  the  brachial  plexus.  In  the 
lower  part  of  this  space  lie  also  the  subclavian  artery  and 
vein.  It  contains,  likewise,  a  loose  cellular  tissue.  This  space  is 
connected  with  that  of  the  posterior  mediastinum  by  means  of  the 
trachea  and  oesophagus;  and  pus  forming  in  the  space  may 
descend  along  these  tubes  into  the  thorax;  or  it  may  follow  the 
trunks  of  the  brachial  plexus  and  appear  in  the  axilla.  The 
strength  and  resistance  of  the  middle  stratum  are  such  that 
tumors  forming  in  the  third  space  are  forced  backwards  and 
laterally,  and  can  cause  perilous  compression  of  vessels  and 
nerves. 

The  fourth  space  which  lies  behind  the  prsevertebral  stratum 
is  filled  with  the  muscles  situated  there;  the  only  other  structure 
of  importance  found  there  is  the  sympathetic  nerve;  and  to  this 
may  be  added  the  vertebral  artery  and  vein  which  traverse  the 
transverse  vertebral  processes. 

Besides  the  blood-vessels  contained  in  the  third  interfascial 
space,  there  lie  there  also,  lymphatic  glands  and  their  vessels;  and 
likewise,  the  termination  of  the  chylo-lymph  trunks,  which  end 
on  both  sides  in  the  vessels  formed  by  the  union  of  the  internal 


804  NECK. 

jugular  and  subclavian  veins.  These  terminal  trunks  should  be 
remembered  in  estimating  the  gravity  of  wounds  which  penetrate 
these  regions. 

The  glands  lie  chiefly  in  the  space  between  tlie  second  and 
third  fascial  strata;  and  a  number,  which  have  a  special  surgical 
importance,  lie  along  the  course  of  the  carotid  artery  and  internal 
jugular  vein;  and  those  in  contact  with  the  vein  are  especially 
to  be  borne  in  mind,  since  when  the  glands  inflame,  they  can 
become  so  adherent  to  the  vein  that  their  removal  by  the  sur- 
geon imperils  the  venous  wall;  or  their  suppurative  action  may 
weaken  and  open  the  vein.  Again,  the  diseased  glands  encroach- 
ing on  the  vein  may  occlude  it  through  the  formation  of  a  tlirom- 
bus  which,  growing  upwards  or  downwards,  may  imperil  life. 

As  stated,  the  antero-lateral  region  of  the  neck  is  a  field  which 
offers  numberless  opportunities  to  surgery  for  operative  interven- 
tion; and  the  facility  or  difficulty  of  such  intervention  is  deter- 
mined by  the  form  of  the  neck;  if  the  neck  be  short  and  thick, 
incision,  excision,  subcision,  ligation  and  other  technical  proce- 
dures become  inconceivably  difficult;  but  if  the  field  is  long, 
spacious  and  accessible,  the  knife  has  freedom  to  do  its  best  work. 
And  these  methods  have  a  bearing,  commonly  unnoticed,  on 
surgical  statistics. 

Torticollis. — As  synonyms  of  torticollis  are  caput  obstipum  and 
wry-neck. 

In  torticollis  the  head,  instead  of  being  erect,  is  deviated  to 
one  side;  and  this  arises  from  a  distortion  or  inclination  of  the 
neck  in  the  same  direction.  The  neck  not  only  leans  towards  one 
side,  but  it  is  also  twisted  on  its  vertical  axis,  so  that  the  face  is 
turned  towards  the  side  opposite  to  that  of  the  cervical  inclina- 
tion: that  is,  the  head  leans  towards  one  side,  while  the  face  is 
turned  towards  the  other  side,  and  the  chin  is  uplifted.  The 
head  is  sometimes  so  fixed  that  the  patient  cannot  move  it,  or 
only  slightly. 

As  classification  of  the  directions  in  which  the  head  may  be 
inclilicd,  that  of  Duval  is  a  convenient  one,  viz.,  anterior,  poste- 
rior, anterior  oblique  towards  the  right  or  left,  and  posterior 
oblique  towards  the  riglit  or  left. 

The  affection  niay  appear  as  a  congenital  deformity;  or  it 
may  arise  after  birth. 

The  head  is  oftener  flexed  towards  the  right  side;  and  from 
the  author's  observation,  torticollis  occurs  oftener  in  the  male  sex. 

If  viewed  in  reference  to  the  anatomicnl  structure  which  is 


TORTICOLLIS,  805 

affected,  torticollis  may  be  designated  cutaneous,  osseous,  muscu- 
lar or  musculo-nervous.  Cuignet  of  Lille  adds  another  species, 
viz.,  ocular  torticollis,  which  arises  from  photophobia  or  diplo- 
pia. 

Congenital  torticollis  studied  in  reference  to  aetiology,  has 
been  explained  in  three  ways :  (1)  Mechanical,  in  which  the  ori- 
gin of  it  is  referred  to  abnormal  pressure  on  the  fretal  head  before 
birth.  This  was  the  theory  of  Hippocrates  and  Dieffenbach.  (2) 
Musculo-nervous,  which  refers  the  origin  to  some  pathological 
condition  of  the  muscles  dependent  on  some  lesion  or  defect  of 
the  nervous  centers.  (3)  Arrest  of  development,  in  which  one 
side  of  the  head  outstrips  the  other  in  growth. 

Von  Ammon,  who  has  made  a  careful  study  of  torticollis, 
finds  a  connection  between  the  greater  frequency  of  the  deform- 
ity on  the  right  side,  and  the  position  of  the  foetus  in  utero :  viz.,  in 
three-fourths  of  the  cases,  the  foetal  head  is  turned  towards  the 
left  side  of  the  mother.  And  this  may  explain  the  fact  that  the 
affection  seems  to  be  inherited  in  some  famihes.  He  also  observed 
that  parts  of  the  foetus  which  are  developed  early  in  utero  are  the 
most  liable  to  congenital  deformity. 

The  deformity  was  seen,  by  Von  Ammon  to  occur  soon  after 
birth  ;  and  in  such  children  there  was  an  abnormal  hardness  and 
density  of  the  contracted  muscle  which  caused  the  deviation. 

The  author  has  seen  cases  which  arose  at  the  time  of  birth, 
and  were  due  to  some  manual  or  instrumental  manipulation  used 
in  the  delivery  of  the  foetus,  viz.,  version,  or  the  use  of  the  for- 
ceps. In  some  of  these  children,  the  violence  done  the  neck  in 
delivery  caused  swelling  and  suppuration  of  the  injured  muscle. 
Duval  has  seen  torticollis  arise  in  the  infant  from  a  glandular 
affection  on  one  side  of  the  neck,  which  causes  the  child  to  incline 
the  head  towards  the  other  side;  thus,  from  habit,  lateral  devia- 
.tion  of  the  head  and  neck  can  arise.  But  if  the  muscles  be 
affected  with  rheumatism,  the  head  will  incline  towards  the 
affected  side. 

The  site  of  torticollis  may  be  in  the  derm,  the  cervical  mus- 
cles and  fascice,  or  in  the  cervical  vertebrae:  or  the  site  may  be 
in  two,  or  in  all  of  these  structures. 

The  removal  of  a  large  portion  of  the  skin  of  the  neck  may  be 
followed  by  a  torticollis;  also  a  burn,  followed  by  a  contractile  or 
keloid  cicatrix,  may  deflect  the  head.  That  arising  from  the 
skin,  which  has  been  wounded  or  removed  by  a  surgical  inci- 
sion, is  rarely  permanent.     iVfter  such  operation  the  writer  has 


8UG  NECK. 

seen  a  teiKlency  to  wry-neck;  and  so  great  was  this  tendency  in 
a  few  cases  that  it  was  necessary  to  use  an  orthopedic  correcting 
appliance.  The  surgeon  may  lessen  cicatricial  deflection,  if  in 
his  operative  work  he  so  plans  the  incisions  or  wounds  made  that 
their  closure  can  be  done  by  vertical  lines,  rather  than  by  trans- 
verse ones. 

Torticollis  from  musculo-fascial  contraction  occurs  much 
oftener  than  from  any  other  cause.  The  muscles  which  are 
implicated  are,  when  named  in  tlieir  anatomical  ordei',  the 
platysma  myoides,  the  sterno-cloido-mastoideus,  the  scaleni,  the 
trapezius,  the  prajverLebral  and  the  retro-vertebral  muscles.  Of 
these  muscles,  the  one  which  is  oftenest  the  causal  agent  through 
its  shortening,  is  the  sterno-cleido-mastoid,  together  with  its  fas- 
cial sheath. 

As  may  be  inferred  from  what  has  been  stated,  the  shortening 
of  the  muscle  is  commonly  due  to  some  lesion,  or  inflammatory 
affection  of  its  tissue;  and  wliere  such  direct  agency  is  not  discov- 
erable, some  recondite  nervous  disturbance  of  central,  interme- 
diate or  peripheral  location,  has  been  sought  for. 

Long  continuance  of  the  contracted  state,  eventuall}^  induces 
changes  in  the  muscular  structure;  thus,  as  the  writer  has  seen, 
the  tissue  of  the  sterno-cleido-mastoid  has  become  changed  into 
dense  tendon-like  structures;  and  this  change  implicated  the 
muscle's  fascial  envelope,  as  well  as  the  overlying  skin.  This 
shortening  was  accompanied  by  incurvation,  so  that  the  retracted 
structures  were  adherent  to  the  cervical  vessels. 

The  third  site  in  which  the  causal  agenc}^  may  be  situated  is 
in  the  superior  cervical  vertebrae.  Some  writers  do  not  include 
under  the  head  of  torticollis  cervical  deviation  which  originates 
in  spinal  affection;  Malgaigne,  however,  in  his  chapter  on  torti- 
collis, gives  this  mode  of  causation  a  prominent  place.  He  finds 
that  torticollis  may  arise  from  a  disease  of  the  joint  connecting 
the  axis  and  atlas;  and  of  the  articulation  which  unites  the  occip- 
ital bone  with  the  atlas.  In  such  cases,  the  site  of  the  disease  can 
often  be  discovered  by  an  examination  of  the  pharynx.  A  swell- 
ing is  thus  detected,  in  which  pus  sometimes  is  found.  The  osse-^ 
ous  disintegration  may  proceed  so  far  that  sub-luxation  can  occur,, 
and  death  ensue;  as  a  rule,  hewever,  the  vertebral  displacement 
is  so  limited  that  it  is  tolerated.  If  the  atlas  be  displaced  on  the 
axis,  the  luxation  is  commonly  forwards;  if  the  displacement  is 
lateral,  then  the  odontoid  process  ceases  to  be  the  center  of  motion, 
and  what  motion  there  is,  is  accomplished  through  the  medium 


TORTICOLLIS.  807 

of  the  adjoining  sound  vertebras.  Or  if  tlie  displacement  between 
the  atlas  and  axis  be  on  one  side,  then  the  rotation  may  be  accom- 
plished through  the  non-luxated  side. 

In  cases  in  which  there  is  a  doubt  whether  the  affection  is 
one  of  inflammation  of  the  joint,  or  of  osseous  disease,  it  is  safe  to 
decide  that  in  severe  cases,  the  bone  is  the  site  of  trouble,  and 
that  disintegration  is  present  or  impending;  and  such  disease  is 
usually  in  tubercular  subjects.  In  such  patients,  the  spinous 
processes  of  the  region  should  be  examined;  and  if  undue  prom- 
inence be  found,  this  denotes  osseous  disease. 

In  cases  of  sub-luxation,  Malgaigne  thinks  that  the  danger 
from  an  attempt  to  effect  reduction  is  not  so  great  as  is  com- 
monly taught. 

As  accompaniments  of  torticollis,  the  following  are  often 
present:  the  face  is  asymmetrical,  arising  from  the  imperfect  or 
arrested  development  of  the  side  on  which  the  distortion  exists. 
The  nose  is  small,  the  cheeks  are  unlike,  the  eyes  of  unequal 
size:  all  the  parts  of  the  face  on  the  inclined  side  are  smaller 
than  those  of  the  other.  And  the  cranium  participates  in  the 
malformation;  it  has  an  oblique,  oval  form;  and  this  is  due 
to  the  half  on  the  affected  side  being  smaller  than  the  other. 
The  cerebral  hemisphere  on  the  affected  side  is  smaller  than  the 
other.  From  this  lessened  cerebral  form,  the  opposite  side  of  the 
body  is  slightly  retarded  in  its  development.  Broca  finds,  also, 
an  impairment  of  intelligence  in  the  subjects  of  congenital 
torticollis. 

This  impaired  development  is  caused  by  the  pressure  on  the 
carotid  artery  on  the  affected  side:  thence  arising  a  lessened 
blood  supply  to  all  the  parts  on  that  side  of  the  head.  Bouvier 
has  verified,  by  the  necropsy  of  such  cases,  the  lessened  calibre 
of  the  carotid  on  the  distorted  side. 

As  functional  symptoms  are  the  following:  the  patient  can 
only  make  limited  movement  of  the  head.  When  at  repose,  the 
patient  experiences  no  pain;  but  when  an  effort  is  made  to  erect 
the  head,  pain  is  caused.  A  shifting  of  the  head  from  the  nor- 
mal position  may  cause  double  vision.  The  movements  of  the 
larynx  are  hampered;  and  phonation  in  some  of  its  acts  is 
restricted.  The  oesophagus  may  be  disturbed  in  form  and  func- 
tion. The  temperature  is  often  slightly  lowered  on  the  affected 
side. 

Paralysis  of  one  sterno-cleido-mastoid,  or  of  other  muscles  on 
one  side,  leads  to  inclination  on  the  sound  side;  in  such  cases, 
the  patient  is  unable  to  move  the  head  on  the  paralyzed  side. 


808  XECK. 

There  is  a  foriii  of  torticollis  which  is  intermittent  or  spas- 
modic in  its  manifestation.  Tlie  affection  is  the  result  of  invol- 
untary contractions  of  the  cervical  muscles,  viz.,  of  the  sterno- 
cleido-mastoid,  the  trapezius  and  splenius.  The  subjects  of  this 
are  affected  differently;  in  one  case,  it  appears  only  when  the 
patient  stands;  in  another,  it  appears  when  he  walks;  and  in  a 
third  class,  it  arises  when  the  patient  makes  movements  peculiar 
to  his  oceu])ation.  In  a  case  of  spasmodic  torticollis  treated  by 
tlic  writer,  the  spasmodic  deviation  of  the  lieud  was  awakened 
by  any  rotatory  movement  of  the  head;  and  the  contractile 
action  was  on  the  left  side,  and  the  head  was  drawn  obliquely 
downwards  and  forwards.  This  spasmodic  act  was  not  continuous, 
but  was  marked  by  momentary,  slight  remissions;  and  these 
cessations  were  not  long  enough  to  allow  the  head  to  assume  its 
erect  position. 

Torticollis,  again,  may  arise  under  some  moral  influence,  as 
anger,  fear  or  depression.  It  has  been  seen  to  appear  at  the 
catamenial  period.  And  it  has  arisen  so  j)eriodically,  that  its 
cause  has  been  referred  to  malarial  poison.  Bo3'er  saw  a  case  in 
which  the  attacks  came  on  when  the  patient  began  dinner;  and 
even  if  the  dining  hour  was  changed,  the  attacks  came  on  as 
previousl}'. 

In  these  cases  of  intermittent  torticollis,  the  attacks  do  not 
appear  when  the  patient  is  asleep.  Asa  rule,  the  spasmodic 
action  is  unilateral;  yet  it  may  attack  simultaneously  both  sides, 
as  was  seen  by  Steudel  in  one  case. 

In  conclusion,  the  attacks  of  spasmodic  torticollis  are,  as  a 
rule,  irregular  in  their  occurrence ;  in  some  cases,  the  recurrence 
has  been  at  long  intervals.  And  the  attacks  are  commonly 
transient  in  duration. 

Treatment. — Torticollis  is  often  amenable  to  medical  treatment; 
and  when  causal  conditions  are  present  which  indicate  that  the 
patient  can  thus  be  cured,  appropriate  remedies  should  first  be 
tried,  and  when  these  have  failed,  some  orthopedic  or  operative 
measure  must  be  resorted  to. 

In  all  cases  of  a  grave  or  obstinate  character,  as  a  diagnostic 
means  to  test  the  extent  and  persistence  of  the  distortion,  the 
patient  should  be  subjected  to  complete  anaesthetic  narcosis;  and 
the  degree  of  the  contraction  being  thus  determined,  the  surgeon 
is  enabled  to  decide  whether  he  should  make  a  preliminary  trial 
of  non-operative  treatment,  or  resort  at  once  to  the  knife.  If,  for 
example,  he  finds  that  the  shortened  muscles  easily  relax,  then  a 


TORTICOLLIS.  809 

non-operative  coarse  may  be  pursued;  and,  as  means  comprised 
under  this  head,  are  electricity,  manipulation,  and  orthopedic 
appliances;  and  in  spasmodic  and  periodically  recurring  cases, 
internal  medication  must  be  employed. 

Electricity  was  employed  by  Duchenne  and  Remak :  the 
former  using  the  interrupted  current,  while  Remak  preferred  the 
continuous  one.  The  continuous  current,  generated  by  a  limited 
number  of  galvanic  elements,  should  be  made  to  pass  from  the 
spine  to  the  lengthened  muscle;  and  this  is  done  by  placing  the 
positive  pole  on  the  spine,  and  the  negative  one  on  the  muscle. 
The  electric  current  in  all  cases,  should  act  on  the  convex  or 
elongated  side  of  the  neck;  it  should  not  be  continued  over 
twenty  minutes,  nor  be  repeated  oftener  than  three  times  a  clay. 
This  treatment  promises  most  in  torticollis  of  spasmodic  charac- 
ter and,  also,  in  those  of  a  paretic,  or  paralytic  natin-e:  the  elec- 
tricity being  applied  to  the  palsied  muscles. 

A  number  of  authorities  liave  reported  excellent  results  from 
manual  manipulation;  among  these  maybe  cited  Seguin  and 
Delore,  who,  with  the  passive  movement,  have  in  some  cases 
combined  volitional  movements  of  the  patient. 

The  plan  of  Delore  is  to  deeply  ansesthetize  the  patient,  when, 
the  trunk  being  held,  and  the  shoulders  depressed  by  an  assist- 
ant, the  surgeon  grasping  the  head  moves  it  in  a  direction  which 
is  the  opposite  of  the  deviation.  These  movements  are  made 
in  tlie  sense  of  flexion  and  rotation;  and,  at  first  mild,  they  are  to 
be  gradually  increased  in  force,  until  the  head  is  restored  to  recti- 
tude. This  can  be  done  in  from  ten  to  fifteen  minutes.  During 
these  movements  the  contracted  parts  are  felt  to  yield  with  a 
crackling  sound.  When  the  neck  is  restored  to  normal  position, 
it  is  to  be  retained  so  by  means  of  a  silicated  immobilizing  appa- 
ratus, between  which  and  the  patient,  a  thick  layer  of  cotton  is  to 
be  placed.  This  retentive  dressing  remains  in  place  a  month, 
when  it  is  to  be  removed,  and  another  applied,  if  a  cure  has  not 
been  accomplished. 

Instead  of  the  silicated  apparatus,  other  surgeons,  after  having 
broken  the  adhesions  and  relieved  the  distortion,  use  an  appliance 
of  fixation  which  can  occasionally  be  removed;  and  they  claim 
that,  by  so  doing,  there  is  less  danger  of  sloughs  from  undue 
pressure,  since  the  apparatus  can  easily  be  removed  and  applied, 
as  exigency  may  demand. 

Internal  medication  must  be  resorted  to  in  cases  of  a  spas- 
modic or  periodic  character,  and  especiallv  in  those  in  whom 
52 


810  NECK. 

there  is  a  suspicion  of  malarial  infection.  In  such  cases,  quinine 
in  full  doses  should  be  administered.  Fowler's  solution  of  arsenic 
may  also  be  given.  In  those  in  whom  there  are  rheumatic 
symptoms,  colcliicum  and  cimicifuga  may  bo  given.  An  addi- 
tional remedy  that  may  be  tried  is  salicylic  acid. 

The  armory  of  electric,  mechanical  and  medical  means  hav- 
ing been  exhausted  with  fruitless  result,  the  knife  remains  as  the 
ultimate  resort:  and  this  opens  the  subject  of  tenotomy  and 
myotomy  of  the  cervical  muscles,  for  the  relief  of  torticollis. 

Tenotomy,  or,  more  properly,  myotomy,  was  first  done  for  the 
relief  of  torticollis  by  Eonhuysen,in  1670;  he  divided  the  sterno- 
cleido-mastoid  by  first  opening  the  skin  and  then  severing  the 
muscle  from  within  outwards,  with  a  bistoury.  Afterwards,  the 
division  of  the  muscle  was  done  with  scissors  by  Florianus;  and 
Minnius  divided  the  muscle,  after  he  had  exposed  it  by  the  aid  of 
an  escharotic  which  destroN^ed  the  superjacent  skin.  This  pioneer 
work  found  but  little  imitation:  in  fact,  it  was  decried,  until  the 
two  master  surgeons  Dupuytren  and  Diefrenbach,  who  flourished 
during  the  first  third  of  the  nineteenth  century,  gave  the  opera- 
tion its  proper  place  in  operative  surgery;  and  priority  in  this 
work  is  assigned  to  Dupuytren  by  Von  Ammon,  a  German 
authority. 

Though  the  operation  is  a  simple  one  and  free  from  ill  conse- 
quences in  most  cases,  yet  this  is  not  the  universal  report;  ill 
results,  and  even  death,  have  followed  it.  Such  ill  results  have 
been  from  wound  of  the  internal  jugular  vein,  injury  to  nerves, 
and  occasionally,  troublesome  sup[)uration. 

The  internal  jugular  has  often  been  wounded;  even  those 
whose  instruments  were  guarded  with  accurate  anatomical  knowl- 
edge have  unwittingly  strayed  from  the  ])rotective  landmarks, 
and  have  pierced  the  internal  jugular.  The  writer  once  saw  this 
happen  in  an  operation  done  by  one  who  was  reputed  to  be  the 
most  skillful  operator  among  those  who  speak  the  English  tongue. 
The  famous  surgeon  had  just  premised  the  work  by  a  few  words 
in  which  he  dwelt  on  the  danger  attendant  on  the  subcutaneous 
section  of  the  sterno-cleido-mastoid ;  "that  though  one  might 
safely  cross  a  bridge  many  times,  yet  if  he  approached  too  near 
the  edge,  he  might  fall  into  the  river;"  and  having  said  this,  he 
inserted  his  tenotome,  and  the  gush  of  blood  which  instantly 
flooded  the  parts,  showed  that  he  had  wandered  off  the  "Waterloo 
bridge,"  and  fallen  into  the  river. 

Bonnet  claims  that  a  puncture  of  the  internal  jugular  vein  is 


TORTICOLLIS.  811 

free  from  danger;  yet  Gue'riu  and  Vallin  teach  the  contrary,  and 
advise  to  scrupulously  avoid  the  vessels.  In  one  case,  death 
resulted  frona  a  wound  of  the  internal  jugular. 

Philippe,  in  1847,  wrote  on  the  operation,  and  announced  that 
he  had  seen  ill  effects  follow  myotomy  in  the  neck.  He  has 
collected  five  cases  in  which  the  injury  to  certain  unim2)ortant 
nerves  caused  paralysis  of  parts.  In  one  case,  Phili^Dpe  divided 
subcutaneously  the  clavicular  portion  of  the  sterno-cleido-mastoid, 
and  in  the  operation  some  small  nerves  were  cut,  whence  a 
neuritis  was  awakened,  that  extended  to  adjacent  nerves,  and 
produced  palsy  of  the  arm.  This  palsy  finally  extended  to  the 
facial  nerve.  The  writer  cannot  refrain  from  remarking  that  tlie 
tenotome  here  may  inadvertently  have  wandered  from  the  route 
appointed  for  it,  and  encroached  on  structures  of  which  an  injury 
is  punished  with  fatal  forfeit. 

A  third  ill  result  of  myotomy  and  tenotomy  is  suppuration  ; 
it  is  probable,  however,  that  careful  asepticism  will  strike  tins 
out  from  the  list  of  accidents  which  may  follow  these  operations. 

Upon  the  point  whether  cases  may  be  cured  without  an  oper- 
ation, Dieffenbach  admits  that  they  can ;  yet,  that  when  the  non- 
operative  course  is  pursued,  the  treatment  is  more  tedious  and 
prolonged,  and  relapses  are  not  infrequent.  In  fact,  where  only 
orthopedic  means  have  been  used,  Dieftenbach  has  seen  the 
muscles  rebel  and  contract  still  more  than  they  were  before. 

As  a  guiding  rule  on  this  subject,  Guerin  says  that  while  the 
muscle  is  yet  in  the  condition  of  mere  contracture,  a  cure  can  be 
effected  mechanically;  but  when  the  muscle  has  reached  the 
stage  of  permanent  contraction,  orthopedic  appliances  fail, 
unless  the  muscle  be  divided;  and  the  reason  of  this  is,  that  in 
the  former,  the  muscle  is  in  a  normal  state,  and  can  easily  be 
extended;  but  wlien  the  muscle  has  passed  into  permanent  con- 
traction, it  has  undergone  a  fibrous  change  that  does  not  permit 
of  elongation. 

The  section  may  be  done  at  an  early  age,  as  was  verified  by 
Dieffenbach,  who  operated  on  two  infants  which  were  only  six 
months  old. 

The  sterno-cleido-mastoideus  is  the  muscle  usually  contracted 
in  torticollis;  and,  as  a  rule,  the  sterno-mastoid  is  the  portion 
affected;  so  that,  in  many  cases,  the  operation  is  limited  to  this 
portion;  but  in  cases  which  have  continued  for  years,  in  which 
fibrous  change  has  occurred,  it  is  generally  necessary  to  divide 
both  portions  of  the  muscle. 


812  NECK. 

The  point  at  which  section  is  made  lies  in  the  lowermost 
portion  of  the  muscle,  viz.,  from  a  lialf  inch  to  an  incli  above  the 
sternal  and  clavicular  endings.  The  section  was,  sometimes,  done 
liigher  l)y  Malgaigne.  In  the  liigli  division,  the  spinal  accessory' 
nerve  sliould  be  borne  in  mind. 

Where  the  skin  is  contracted  into  a  fibrous  cord,  Dieffenbach 
first  removed  the  contracted  portion,  and  then  closed  the  wound; 
some  weeks  afterwards,  he  divided  the  shortened  mu.scle  subcu- 
taneously,  and  thus  effected  a  cure.  In  a  normal  case  of  con- 
tracted sterno-cleido-mastoid,  he  divided  the  n)uscle,  at  once,  as 
follows:  if  the  contraction  were  on  the  right  side,  having  seized 
and  lifted  up  the  muscle  with  the  left  hand,  then,  with  the  right 
hand,  he  pushed  the  tenotome  between  the  trachea  and  muscle, 
underneath  the  latter,  and  thus  severed  the  muscle  from  beneath 
towards  the  skin.  As  he  cut,  he  pressed  the  skin  and  tendon 
with  the  thumb  of  the  hand.  Having  divided  the  sternal  por- 
tion he  next  passed  the  knife  in  the  fossa  beneath  the  clavicular 
I)ortion,  and  divided  this. 

In  some  cases  operated  on  b}^  Bonnet,  after  dividing  the 
sternal  and  clavicular  portions  of  the  muscle  below,  at  a  later 
period,  he  divided  the  body  of  the  muscle  an  inch  and  a  half 
higher  up. 

There  has  been  a  controversy  whether  the  cutting  should  be 
done  from  before,  backwards,  or  reversely;  and  also  whether  the 
knife  should  enter  on  the  inner  or  outer  side  of  the  muscle. 
Bonnet  thinks  it  is  unimportant  which  way  the  work  is  done. 
When  he  divided  the  muscle  in  its  body,  he  cut  from  behind 
forwards;  but  when  he  cut  but  one  portion,  he  severed  from 
before,  backwards.  After  the  division,  should  it  appear  that 
certain  fibres  are  unsevered,  or  that  the  shea-th  has  not  been 
included  in  the  division,  then  a  blunt  knife  may  be  passed  behind 
these  parts,  and  their  division  effected.  In  the  young  subject, 
liowever,  the  sheath  may  be  allowed  to  remain  unsevered;  thus 
doing,  one  obtains  better  reunion  of  the  divided  muscle. 

As  soon  as  the  division  is  done,  the  site  of  puncture  should  be 
compressed  so  as  to  check  any  bleeding  which  may  follow. 
Should  a  re-division  of  the  muscle  be  necessary,  Duval  counsels 
not  to  repeat  the  cutting  in  the  same  place;  lie  cuts  at  a  new 
point,  and  thus  there  is  le.ss  danger  of  wounding  the  vessel  that 
has  become  attached  to  the  muscle  through  the  previous  cutting. 

Dieffenbach,  who  operated  a  countless  number  of  times,  found 
the  seat  of  the  trouble  in  most  cases,  to  be  in  the  sternal  portion 


TORTICOLLIS.  813 

of  the  sterno-cleido-mastoid  muscle;  he  divided  this  a  hah"  inch 
above  the  sternum.  Should  it  be  necessary  to  sever  both  por- 
tions, he  thrusts  his  tenotome  on  the  inner  side  of  the  inner  por- 
tion, and  on  the  outer  side  of  the  outer  portion ;  and  cuts  both 
portions  from  behind,  forwards. 

The  site  of  the  muscular  contraction  has  been  found  to  exist 
in  the  platysma  myoides;  also  in  the  scalene  muscles,  lateral 
portion  of  the  trapezius  and  in  the  muscles  behind  the  neck;  of 
the  retro-cervical  muscles,  the  trapezius  and  complexus  are  the 
ones  oftenest  at  fault.  In  whatever  muscle  the  contraction  exists, 
this,  in  most  cases,  maybe  divided  subcutaneously ;  should,  how 
ever,  the  muscle  not  be  safely  accessible  in  this  wa}^  as,  for  exam- 
ple, the  deep-seated  scalenus,  then  the  muscle  should  be  dis- 
played by  an  open  incision,  and  divided  to  the  extent  required. 
The  more  superficial  muscles,  as  the  platysma  myoides  and  the 
trapezius,  may  be  severed  subcutaneously;  3^et  the  latter,  if  the 
operator  has  not  recently  verified  the  site  of  the  spinal  accessory 
nerve,  is  more  safely  divided  by  open  incision.  And  the  depth 
of  the  scalene  muscles  is  such  that  they  can  only  be  reached  and 
divided  by  an  open  incision,  as  Bauer  did. 

In  cases  of  spasmodic  and  periodic  torticollis  which  have 
resisted  internal  medication,  a  resort  may  be  had  to  neurectomy 
of  the  spinal  accessory  nerve,  and  the  branches  of  the  superficial 
cervical  plexus. 

The  spinal  accessory  lies  above  in  a  four-sided  figure,  of  which 
the  boundaries  areas  follows:  draw  a  horizontal  line  from  the 
angle  of  the  jaw  backwards,  and  a  second  one  on  a  level  with  the 
upper  boundary  of  the  thyroid  cartilage,  then  draw  two  other 
lines,  one  in  front  of  and  another  behind  the  sterno-cleido- 
mastoid  ;  then  a  diagonal  line,  drawn  from  the  upper  and  inner 
angle  of  this  figure  to  the  lower  and  outer  angle,  will  lie  over  the 
nerve.  It  usually  pierces  the  sterno-cleido-mastoideus;  yet  the 
writer  has  found  exceptions  to  this  in  his  dissections.  The 
branches  of  the  superficial  cervical  plexus  escape  from  the  pos- 
terior border  of  the  muscle,  near  the  union  of  the  upper  and  the 
middle  thirds  of  the  muscle. 

Campbell  de  Morgan  having  failed  to  cure  a  case  of  torticollis 
by  myotomy,  afterwards  exsected  a  portion  of  the  spinal  accessory 
nerve,  with  successful  result.  The  writer  treated  a  case  of  obsti- 
nate spasmodic  torticollis,  which  was  unilateral,  and  which  was 
not  benefited  by  myotomy;  the  patient  was  finally  cured  by 
neurectomy  of  the  spinal  accessory  nerve  and  all  the  branches  of 
the  superficial  cervical  plexus. 


814  XECK. 

In  recent  times  (1SS5)  Volkmanu  has  done  this  work  by 
open  incision;  and  having  the  parts  exposed  fully  to  view,  he 
divided  freely  the  parts  necessary  to  rectify  the  head  ;  this  plan  is 
analogous  to  tliat  of  Price,  who,  having  made  an  opening,  passed 
a  grooved  director  under  the  muscle,  and  divided  it. 

After  the  myotomy  was  done,  Eulenberg's  practice  was  to 
forcibly  restore  the  head  to  normal  position;  and  after  breaking 
up  any  adhesions  which  opposed  this — the  head  was  tlien  allowed 
to  resume  its  abnormal  position,  and  to  remain  thus  for  three 
davs;  then  it  was  straightened  and  maintained  erect  by  mechan- 
ical appliances. 

After  myotomy,  Petrali  advises,  before  the  application  of  a 
mechanical  support,  to  bring  tlie  shoulders  to  a  horizontal  posi- 
tion, and  having  lifted  the  head  to  an  erect  posture,  let  it  be 
moved  in  the  arc  of  a  circle  which  is  the  opposite  of  tlie  ill  posi- 
tion; and  lastly,  any  secondary  curves  of  the  spine  lower  down, 
must  be  corrected;  and  thus  rectified,  the  jDarts  must  be  main- 
tained in  place  by  orthopedic  apparatus. 

Inventive  genius  has  given  the  surgeon  mechanical  appliances 
of  diversified  models,  to  maintain  the  parts  in  rectitude  after 
division  of  the  contracted  muscles;  and  it  is  through  the  judicious 
selection  and  proper  use  of  these  means,  that  the  cure  is  finally 
obtained;  for,  from  the  writer's  observation,  there  is  no  thing 
which  is  more  strongly  impressed  on  the  surgeon  through  his 
experience  than  that,  however  much  his  knife  may  aid  him  in 
this  work,  it  is  through  the  slow  plodding  effort  of  well-devised 
orthopedic  appliance  that  the  ultimate  link  in  the  cure  of  torti- 
collis is  reached ;  the  tenotome  is  merely  the  key  that  opens  the 
gate  of  the  field  in  which  lies  his  chief  work. 

The  orthopedic  appliances  used  in  the  treatment  of  torticollis 
may  be  classed  in  the  following  groups:  (1)  A  simple  cravat. 
(2)  A  cravat  with  apparatus  for  fixing  the  head.  (3)  An  appa- 
ratus for  fixing  the  head  in  rectitude  which  is  attached  to  one 
fastened  about  the  upper  part  of  the  trunk. 

In  mild  cases,  or  those  of  recent  origin,  after  the  tenotomy  of 
the  sterno-clcido-mastoid  muscle,  the  cure  may  be  acccomplished 
by  the  use  of  a  stiff  cravat,  which  will  prevent  the  head  from 
resuming  the  former  false  position.  Such  an  appliance  can  be 
made  of  felt  pasteboard,  leather,  gutta  percha,or  of  metal. 

In  the  second  group,  the  cravat  is  combined  with  some  appli- 
ance fastened  about  the  head;  and  the  latter  maybe  a  simple 
ring,  to   which  straps  are  fastened    which   are  attached  to  the 


TORTICOLLIS.  815 

cravat  at  points  wliicli  will  permit  traction  to  be  made  in  such 
directions  as  will  best  maintain  the  normal  rectitude  of  the  head. 
Or  these  straps  may  be  fastened  to  padded  rings  through  which 
tlie  arms  pass;  and  tliese  rings  rest  on  the  shoulders.  Either  of 
these  orthopedic  apparatuses,  though  it  restores  the  head  to  proper 
position,  may  act  faultily  by  lifting  the  shoulder  abnormally 
high;  that  is,  when  the  head  is  brought  to  proper  position,  the 
structures,  which  are  abnorrnally  short  on  the  affected  side, 
lift  the  shoulders  upwards.  And  in  a  cure  thus  obtained,  the 
correction  would  consist  in  an  exchange  of  a  distortion  of  the 
neck  for  one  of  the  shoulders.  Bonnet  has  invented  an  appara- 
tus in  which,  besides  the  thoracic  portion,  there  is  a  neatly  fitting, 
well-padded  cravat,  and  there  ascend  from  the  shoulders  two 
uprights,  to  which  are  fixed  rods  which  press  pads  against  the 
face.  The  pads  can  be  fixed  at  different  points,  and  by  their 
pressure,  the  head  can  be  made  erect  and  rotated,  and  the  face 
turned  towards  the  sound  side.  The  apparatus  of  Bonnet  is  shown 
in  Figure  92,  from  which  its  mode  of  action  can  be  understood. 


Figure  92.     Apparatus  of  Bonnet  for  correcting  torticollis. 

An  apparatus  has  been  devised  b}''  Bigg,  of  London,  which  is 
light  in  construction,  and  is  composed  of  the  following  parts:  a 
light  pelvic  girdle  to  which  a  dorsal  stem  is  fastened;  to  this  is 
attached  above  another  light  girdle,  which  encircles  the  chest 
and  passes  close  to  the  arms  in  the  axillary  spaces;  and  to  the  dor- 
sal upright  stem  there  is  fastened  a  vertical  piece  which  divides 
above  into  two  branches,  of  which  the  parts  pass  respectively  to 


810  NECK. 

the  right  and  left  sides  of  the  face.  These  latter  branches  are 
fastened  to  pads  which  rest  against  the  sides  of  the  face,  antl 
through  them  graduated  compression  can  be  made.  The  two 
braneiies  are  so  arranged  that  the  head  can  be  fixed  in  any  posi- 
tion which  is  desired. 

Malgaigne,  as  appHance,  used  a  corset  to  which  were  fas- 
tened axiUary  crutches,  and  a  dorsal  upright  staff  to  which 
retentive  head-pieces  were  fastened.  The  head-gearing  con- 
tained an  attachment  for  support,  similar  to  what  is  known 
as  the  "jury  mast."  Orthopedic  apphances  have  recently  been 
devised,  analogous  to  those  described,  by  which  continuous  trac- 
tion is  maintained  by  means  of  elastic  cords  or  straps.  From 
the  writer's  experience  the  advantages  claimed  for  these  stra[)S 
are  less  than  their  inventors  assert;  they  soon  wear  out,  or  become 
weak,  and  demand  constant  renewal. 

Among  means  to  restore  to  normal  position,  after  division  of 
the  contracted  structures,  should  be  mentioned  traction  and 
counter-traction  made  on  the  head  and  trunk.  This  method  is 
strongly  advised  by  Stromeyer.  For  this  work  special  beds 
have  been  constructed,  of  a  complicated  character.  Since  the 
introduction  of  the  weight  and  pulley  to  maintain  traction,  the 
work  is  simplified  by  converting  the  bed  into  an  inclined  plane, 
and  making  attachment  of  the  pulley  to  the  head  of  the  bed,  and 
fastening  the  tractile  appliance  to  the  head.  Despite  the  emi- 
nent authority  of  Stromeyer,  his  extension  plan  has  not  met  with 
general  acceptance;  in  fact,  Malgaigne  utterly  discards  it;  and 
South  disapproves  of  it. 

From  the  writer's  observation,  there  are  cases  of  torticollis  in 
which,  after  2:)rei)aratory  myotomy,  tiie  surgeon  will  find  it  impos- 
sible to  return  the  head,  neck  and  shoulders  in  proper  i)lace  by 
the  use  of  any  of  the  ordinary  orthopedic  appliances.  In  such  a 
case,  treated  by  the  author,  in  which  the  usual  instruments  did 
not  effect  the  desired  correction,  a  satisfactory  result  was  obtained 
through  the  application  of  a  gypsum  apparatus,  applied  as  fol- 
lows: the  patient  sitting  on  a  stool  with  the  head,  neck  and 
shoulders  brought  into  proper  position,  must  have  these  parts 
well  enveloped  in  cotton  w^adding,  and  firmly  held  in  place  while 
the  plaster  dressing  is  being  applied.  For  this  maintenance  in 
position  three  assistants  are  necessary:  viz.,  one  to  hold  each  arm, 
and  a  third  to  fix  the  head.  In  spite  of  this  care,  there  may  be 
some  error  in  position  found  after  the  dressing  has  been  applied. 
Such  error  mav  be  that  the  chin  is  too  high,  and  deviates  from 


TORTICOLLIS.  817 

the  mediaii  line;  and  that  the  shoulders  do  not  stand  on  a  level; 
such  were  the  faults  of  position  which  the  author  found  difficult 
to  avoid;  and  it  was  only  after  repeated  applications  that  such 
faulty  position  was  avoided.  The  gypsum  bandage  must  encircle 
the  chest,  shoulders,  neck  and  head,  crossing  in  a  figure  of  eight 
manner.  The  ears  should  not  be  covered,  and  the  arms  only  so 
covered  as  to  immobilize  the  shoulder  joints.  Such  a  cast  should 
be  worn  for  three  months;  and  if  the  deformity  be  great  and  of 
long  standing,  a  longer  period  will  be  required.  During  its 
use  the  patient  can  be  allowed  to  walk  and  use  the  limbs  not 
included  in  the  cast.  And,  for  the  continuance  of  the  correction 
which  has  thus  been  obtained,  some  one  of  the  numerous  ortho- 
pedic appliances  in  vogue  may  be  selected,  and  worn  for  from  six 
to  twelve  months. 

In  cases  of  many  years'  standing,  though  the  faulty  position 
may  be  greatly  amended  by  treatment,  yet  it  is  impossible  to 
comj^letely  restore  the  subject  to  normal  position  and  natural 
figure.  The  long  continuance  of  the  lateral  deviation  has  altered 
the  forms  of  the  cervical  vertebrte;  the  lessened  supply  of  blood 
to  the  affected  structure  has  rendered  those  parts  smaller;  so  that 
though  the  head  be  rectified  in  position,  yet  one  side  of  the  face, 
one  eye,  and  one-half  of  the  skull  will  remain  somewhat  dwarfed, 
or  malformed.  And,  for  a  time,  vision  is  often  disturbed  after 
rectification  of  the  head;  but  the  diplopia  or  obliquity  of  vision, 
thence  arising,  finally  disappears. 

A  method  of  corrective  fixation,  in  cases  in  which  the  hair  is 
long  enough,  is  to  make  two  braids  of  this,  and  tie  these  around 
the  shoulder  of  the  elongated  side.  The  lawlessness,  falsely 
named  liberty,  indoctrinated  into  the  modern  child,  was  evi- 
dently left  out  of  account  b\'  the  writer  who  advised  this  tricho- 
pedie  procedure. 

In  cases  of  torticollis  in  which  the  causal  agency  consists  of 
an  affection  of  some  of  the  cervical  vertebra,  it  is  seldom  that 
tenotomy  need  be  resorted  to.  The  shortened  muscle  or  mQscles 
are  in  a  condition  of  simple  contracture,  which  readily  yields,  if 
the  spinal  column  be  rectified.  A  most  troublesome  task,  how- 
ever, is  often  encountered  in  the  effort  to  straighten  the  spine;  and 
this  is  still  more  aggravated  if  there  be  added  the  complication 
of  an  abscess  arising  from  tubercular  disease.  In  such  cases, 
an  apparatus,  so  devised  as  to  remove  the  most  of  the  weight 
from  the  spinal  column,  must  be  applied  and  worn.  The  con- 
sideration of  the  method  here  referred  to  belongs  rather  to  the 


818  xi'XK. 

subject  of  special  deformity;  and  in  the  chapter  devoted  to  this, 
tlie  matter  will  be  briefly  considered  by  the  writer. 

The  cha|)ter  will  conclude  with  a  mention  of  a  form  of  torti- 
collis which  originates  in  some  lesion  of  the  soft  parts  of  the 
neck,  and  may  be  called  cicatricial. 

In  the  removal  of  neoplasms  from  the  neck,  in  which  a  large 
tract  of  derm  is  sacrificed,  and  the  wound  is  allowed  to  heal  by 
graimlation,  the  head  becomes  drawn  towards  the  affected  side. 
Such  lesion  may  be  a  burn,  by  which  the  skin  being  destroyed,  a 
slow-healing  wound  remains.  The  scar  there  formed  is  thick 
and  contractile,  and  of  the  nature  of  the  semi-malignant  structure 
named  keloid.  In  all  such  cases,  in  which  an  agency  exists  dis- 
posing to  distortion  of  the  neck,  the  tendency  to  deviation  should 
be  op[)Osed  by  a  supporting  and  restraining  apparatus.  Such  an 
appliance  may  consist  of  a  simple  cap  fastened  to  the  head,  and 
from  which  straps  or  cords  may  pass  to  a  girdle  around  the 
up})er  ])ortion  of  the  chest. 

Sometimes  these  cases  only  apply  for  surgical  relief  alter  the 
scar  has  been  formed;  especially  is  this  seen  where  burns  on  the 
neck  have  healed  badly,  or,  percliance,  have  not  healed  at  all. 
In  such  a  case  the  writer  has  seen  the  head  flexed  forwards,  so 
that  the  chin  almost  rested  against  the  upper  end  of  the  sternum. 
In  this  deformity,  relief  may  be  obtained  by  dissecting  out  the 
cicatricial  structure,  and  replacement  by  sound  skin  borrowed 
from  the  contiguous  surface,  if  sound  derm  exists  there.  Such 
restoring  material  should  consist  of  one  or  more  pedunculated 
flaps,  which  are  carried  into  place  by  circumduction;  and  after- 
wards the  remaining  wounds  are  to  be  closed  by  suture.  Such 
re[)lacing  fla})S  should  be  taken  from  sites  where  their  loss  will 
cause  the  least  possible  tension.  And  during  the  time  of  healing, 
the  head  should  be  immobilized  by  means  of  a  head-dress  pro- 
vided with  straps,  which  are  fastened  to  it  at  such  points  as  will 
secure  antagonism  to  the  tendency  to  deviation.  In  cases  in 
wdiich  closure  by  dermal  flaps  is  not  practicable,  the  process  of 
Thiersch  may  be  resorted  to,  in  wdiich  large  epidermal  grafts 
obtained  from  the  femoral  or  humeral  region,  are  transplanted 
to  the  wounded  surface. 


CHAPTER  XXYL 


CONGENITAL    CLEFTS    OR    FISTULJE    IN    THE    NECK. 

These  clefts  which  are  of  congenital  origin,  are  related  to,  and 
arise  from,  incomplete  closure  of  the  primitive  branchial  fissures, 
which  are  present  in  the  development  of  the  embryo. 

In  the  upper  part  of  the  anterior  face  of  tlie  embryo,  in  its 
early  development,  Dzondi  discovered  certain  openings,  which  he 
named  tracheal  fistulse.  Afterwards  Heusinger,  of  Marbourg, 
made  a  careful  study  of  these  congenital  clefts,  of  which  he  col- 
lected forty-eight  cases  in  German  medical  literature;  and  Heu- 
singer attributed  them  to  an  arrest  of  the  normal  embryonic  fis- 
sures. 

For  the  comprehension  of  this  matter,  a  short  rehearsal  of  the 
embryological  constituents  of  the  face  and  neck  should  precede; 
and,  briefly  enumerated,  these  are  as  follows:  there  are  four 
arches,  and  three  clefts  lie  between  these.  The  first  arch  is  the 
budding  point  of  the  future  structures  of  the  face.  The  second 
arch  contains  the  germinal  elements  of  the  styloid  process,  and  a 
part  of  the  hyoid  bone;  and  the  cleft  between  these  becomes  the 
future  tympanic  cavity,  and  the  Eustachian  tube.  The  third 
arch  forms  the  body  of  the  hyoid  bone  and  the  epiglottis;  and 
the  cleft  between  this  arch  and  the  preceding  is  afterwards  oblit- 
erated. The  fourth  arch  forms  the  future  structures  of  the  neck; 
and  the  cleft  between  the  third  and  fourth  arches  is  afterwards 
closed. 

In  its  primary  period  of  growth,  the  embryo  presents  above, 
on  the  side  towards  which  the  head  is  turned,  a  cavity  which  may 
be  named  the  pharyngeal,  bounded  by  arcii-like  processes,  which 
are  analogous  to  the  costal  arches  which  inclose  the  thorax.  The 
spaces  between  the  arches  above  vanish  during  the  process  of 
development,  except  some  vestiges,  which  remain  in  the  structure 
of  the  auditory  apparatus.  Should  the  branchial  arches  not  pro- 
ceed to  complete  development,  then  some  fissure  will  remain ;  and, 
as  verified  by  observation,  this  occurs,  and  happens  oftenest  in  the 

(819) 


S20  CONGENITAL    CLEFTS   dK    FISTUL.E    IN    THE    NECK. 

site  of  the  second  and  third  arches.  In  this  way  the  existence  of 
congenital  clefts  in  the  anterior  surface  of  the  cervical  region  can 
be  explained. 

This  cervical  defect  has  only  recently  been  observed,  or  if 
observed,  the  observation  has  seldom  been  recorded.  Dupla}^ 
and  Gillette  have  collected  a  list  of  nearly  seventy  cases;  of 
these,  the  greater  part  were  observed  in  Germany. 

The  causal  agency  which  leads  to  an  interruption  in  the  com- 
pletion of  the  branchial  arches  has  not  been  explained;  it  lies 
perhaps  in  the  domain  of  those  obscure,  recondite,  and  probably 
undiscoverable  agencies,  which  presided  over  the  animal  bod}^  in 
its  previous  phases  of  evolution;  and  which,  beginning  with  the 
embryonic  form  that  primordially  is  similar  in  all  vertebrates, 
pursues  such  diverse  paths  to  reach  the  adult  stage. 

Though  the  direct  and  immediate  causes  are  unknown,  yet 
observation  has  noted  certain  indirect  or  contingent  agencies, 
which  seem  to  influence  such  congenital  defect;  and  prominent 
among  these  is  heredity  or  kindred.  During  three  generations 
in  one  family  such  defect  was  noticed  eight  times;  and  in  one 
family,  of  eight  children,  five  were  the  subjects  of  the  fissure. 
Other  collateral  defects  often  coexist  with  them,  especially  defects 
of  the  ear  and  face. 

Duplay  divides  such  defects  into  those  which  are  congenital, 
or  exist  at  birth,  and  those  which  appear  afterwards ;  the  latter 
class  is  rare. 

The  branchial  fistula  may  be  complete  or  incomplete;  the 
former  having  an  inner  and  outer  opening,  while  the  incomplete 
may  be  a  blind  canal,  which  opens  on  the  inside,  or  on  the  out- 
side. 

The  complete  fistula  has  a  dermal  outlet,  and  it  opens  into  the 
pharynx.  This  form  is,  according  to  Gusset,  often  associated 
with  imperfect  pulmonary  development.  The  opening  outside 
may  be  situated  at  any  point  from  the  thyroid  cartilage  to  the 
sterno-clavicular  articulation.  The  higher  the  dermal  opening 
is,  the  more  it  ap])roaches  the  median  line.  This  opening  may 
be  fine  and  on  a  level  with  the  skin,  or  somewliat  uplifted  on  a 
reddish  papilla;  and  sometimes,  the  outlet  has  a  valve-like  fold 
of  skin  as  a  covering.  Instead  of  a  fine  opening,  the  outlet  may 
be  much  larger,  viz.,  two  or  three  lines  in  diameter;  this,  how- 
ever, is  exceptional,  and  the  outlet  may  be  so  attenuated  that  a 
fine  probe  can  not  enter  it.  When  the  opening  is  large  enough 
for  inspection,  one  finds  it  invested  with  a  coating  similar  to  that 


COXGEXITAL    CLEFTS    OR    FISTUL.E    IX    THE    XECK.  821 

of  mucous  membrane.  Tiie  canal  between  the  outlets  varies  in 
caliber;  and  may  be  uniform  in  dimensions,  or  with  one  or  more 
dilatations.  It  may  be  straight  or  sinuous.  The  internal  orifice 
opens  into  the  pharyngeal  cavity;  and  this  may  be  above  and 
near  the  greater  cornu  of  the  hyoid  bone;  or  it  may  be  near  the 
palato-phar3'ngeus  muscle;  and  this  inlet  may  be  small  and  dif- 
ficult to  discover;  or  it  may  be  a  pocket-like  opening,  in  which 
mucous  or  alimentary  materials  may  lodge. 

The  external  fistula,  which  is  incomplete,  may  end  at  a  varia- 
ble distance  from  the  cutaneous  surface;  this  canal  points  towards 
the  hyoid  bone,  and  is  dilated  at  its  blind  ending. 

There  lias  been  some  contest  concerning  the  incomplete  fistula, 
which,  opening  in  the  inner  mucous  surface,  descends  thence 
towards  the  skin.  Some  claim  tliat  such  fistula  originates 
through  a  hernial  protrusion  outwards  of  the  mucous  membrane. 

There  have  been  observed,  located  somewhere  near  the  inner 
end  of  the  branchial  canal,  fragmentary  plates  of  cartilage,  or  of 
cartilage  and  bone;  and  these  lodged  on  the  wall  may  vary  from 
a  line  to  an  inch  or  more  in  length.  Such  cartilaginous  lamella 
is  movable,  and  is  not  adherent  to  the  skin.  And  Duplay  has 
seen  similar  plates  of  cartilage  in  the  structures  of  the  front  of  the 
neck  where  no  fistulous  opening  existed.  And  such  cartilage  has 
been  seen  so  prominent  that  it  was  a  source  of  inconvenience, 
and  its  removal  demanded. 

A  fistulous  canal  similar  to  those  described  has  appeared 
some  time  after  birth.  Duplay  has  called  attention  to  this  species, 
and  his  explanation  of  it  is  as  follows:  A  fi.stula  which  opens 
internally  at  birth,  may  be  covered  with  a  film-like  epidermal 
coat;  afterwards,  materials  entering  the  canal,  the  outer  terminal 
covering  may  be  abraded  and  opened;  and  thus  an  incomplete 
canal  becomes  a  complete  one.     Such  cases  are  extremely  rare. 

Besides  the  anatomical  characteristics  of  the  branchial  fistula 
which  have  been  pointed  out,  its  leading  clinical  characteristics 
are  the  discharge  of  material  from  its  external  outlet,  when  the 
latter  exists;  also,  the  collection  and  temporary  sojourn  of  such 
matters  within  the  canal  itself,  and  finally,  the  irritation  wliich 
such  materials  may  cause  while  lodged  in  the  canal,  or  after 
their  escape  from  it. 

The  canal  is  painless  unless  a  sound  be  passed  into  it ;  this 
act  awakens  an  unpleasant  sensation,  or  even  pain  of  a  pricking 
or  burning  character.  In  a  case  in  wliich  the  author  was  con- 
sulted, the  passage  of  a  probe  was  painful  to  the  patient.     This 


822  CONGENITAL    CLEFTS    OK    FISTUL.E    IN    THE    NECK. 

fistula  eiifU'd  blindly;  lienee  the  irritation  awakened  by  the  probe 
did  not  arise  from  itscontact  with  the  inner  surface  of  the  mucous 
passages. 

To  make  an  accurate  diagnosis  of  the  nature  of  such  a  (istula, 
colored  fluid  must  be  injected  into  the  outer  end;  and  for  this 
purpose,  milk  is  one  of  the  most  harmless  that  can  be  selected. 
If  the  canal  have  no  opening  inwards,  the  injected  fluid  would 
regurgitate  to  the  surface  again;  but  if  it  be  complete,  it  would 
enter  the  air-passage  and  produce  cough.  The  previous  history 
would  show  whether  the  fistulous  canal  may*  have  arisen  from  a 
ruptured  bursa  in  the  hyoid  region,  or  from,  a  gland  that  has 
suppurated,  and  opening  on  the  surface,  has  left  an  unhealing 
sinus.  Such  fistulous  canal  might  occupy  the  usual  site  of  a 
branchial  fistula;  yet  the  attendant  phenomena  of  the  former, 
and  the  character  of  the  discharge,  would  clearly  distinguish  the 
former  from  a  branchial  orifice.  The  branchial  fistula  is  often 
associated  with  disturbrnce  of  the  functions  of  respiration  and 
deglutition.  Sarazin  who  has  collected  facts  bearing  on  this 
matter,  finds  that  in  fifty  cases,  ten  of  them  had  some  pulmonary 
trouble,  such  as  catarrh,  emphysoma,  tuberculosis  or  pneumonia. 
Such  fistula  rarely  disappears  spontaneously;  still  Duplay  saw 
a  case  which  did  thus  close. 

Treatment. — The  majority  of  surgeons  oppose  operative  inter- 
vention in  the  complete  fistula;  or  they  limit  the  work  to  merely 
an  attempt  to  convert  the  complete  canal  into  an  incomplete  one 
which  only  opens  externally. 

As  means  used  in  the  treatment  of  branchial  fistula  are  the 
following:  irritant  injections,  thermal  cauterization  and  excision. 

Injections,  which  have  a  destructive  or  escharotic  action  on 
the  lining  of  the  canal,  have  been  commended ;  and  as  such  may 
be  tried,  the  tincture  of  iodine,  a  strong  solution  of  nitrate  of  sil- 
ver, or  one  of  chloride  of  zinc.  Such  means  could  not  be  safely 
used,  in  case  the  fistula  be  incomplete;  for  the  entrance  of  the 
irritant  fluid  into  the  air-passages  must  act  injuriously.  Hence, 
such  treatment  should  be  reserved  for  the  incomplete  canal. 

The  thermal  cautery,  in  the  form  of  the  heated  galvanic 
wire,  or  an  iron  wire  or  probe  that  has  been  heated  to  a  red  heat, 
may  be  used;  and  such  cauterization  may  be  employed,  not  only 
in  the  incomplete  fistula,  but  in  that  which  is  complete,  since 
differing  from  the  escharotic  injection,  the  heat  can  have  no  ill 
action  on  the  air-passage,  or  alimentary  canal. 

The  methods  mentioned  are  tedious  and  less  direct  than  an 


THYROID    GLAND    AND    ITS    AFFECTIOXS.  823 

immediate  attack  with  the  kuife.  Sarazin,  AVeiiilechner  aiid 
Broca  have  practiced  excision  of  tiie  walls  of  the  fistula,  and  have 
effected  cures,  Saraziii's  metliod  was  to  introduce  an  elastic 
sound  into  the  canal,  and  cut  this  off  on  a  level  with  the  skin. 
Then  by  a  circumscribing  cut  the  walls  of  the  canal  were  dis- 
sected wholly  out,  along  with  the  sound.  Or  the  canal  might  be 
distended  by  injecting  melted  wax  into  it,  and  then  excision  be 
done. 

As  such  fistula  causes  but  slight  inconvenience,  non-interven- 
tion is  the  wiser  counsel  to  the  patient.  Such  was  the  course 
pursued  in  a  case  which  consulted  the  writer;  in  this  patient,  the 
incomplete  external  fistula  opened  about  midway  between  the 
angle  of  the  lower  jaw  and  the  sterno-clavicular  joint.  This 
course  is  still  further  justified  by  the  fact  that,  after  the  closure 
of  such  branchial  fistula,  the  patient  has  found  that  the  site  of 
the'healed  canal  is  the  seat  of  unpleasant  sensations  greater  than 
before  it  was  interfered  with. 

THYROID    GLAND,    AND    ITS    AFFECTIONS. 

Surgical  Anatomy. — The  thyroid  gland,  according  to  Allan 
Burns,  lies  a  little  below  the  cricoid  cartilage,  its,  upper  margin 
being  generally  parallel  to  the  second  ring  of  the  trachea.  It 
is  generally  composed  of  two  lobes,  which  are  joined  to  each 
other  by  a  slip  which  crosses  the  trachea,  a  few  lines  below  the 
cricoid  cartilage.  In  one  case  Burns  saw  this  isthmus  placed 
between  the  trachea  and  oesophagus;  a  peculiarity,  he  says,  at  all 
times  to  be  much  dreaded. 

This  description,  given  by  an  eminent  pioneer,  will  here 
receive  some  supplementary  completion  by  material  furnished  by 
Marchant,  in  his  essay  upon  the  thyroid  gland. 

Viewed  as  a  whole,  the  gland  is  in  the  form  of  a  crescent,  of 
which  the  convexit}^  is  directed  downwards,  and  the  branches 
point  upwards.  This  convex  border  has  a  notched  depression 
in  it.  The  gland  has  an  anterior  and  a  posterior  face,  an 
upper  and  lower  and  lateral  borders,  and  a  median  portion, 
named  the  isthmus.  The  posterior  surface  contains  an  excava- 
tion or  semi-canal,  in  which  the  air-passage  and  oesophagus  lie; 
and  the  isthmian  band  lies  on  two  or  three  of  the  upper  tracheal 
rings.  The  recurrent  laryngeal  nerve  lies  close  to  the  posterior 
face.  The  upper  border,  as  a  rule,  lies  close  to  the  cricoid  carti- 
lage. The  inferior  border  is  thick,  short,  and  is  often  concave; 
and  from  this  border  nass  the  tliA'roid  veins.     This  inferior  bor- 


824  THYROID    (JLANI)    AND    ITS    AFFECTIONS. 

der  in  the  adult,  lies  nearly  one  inch  above  the  superior  margin 
of  the  sternum;  and  in  the  infant,  the  distance  is  somewhat  over 
a  half  inch.  If,  however,  the  head  be  well  retro-flexed,  then  the 
distance  between  the  sternum  and  gland  is  increased  nearl}'  a 
half  inch.  The  lateral  borders  which  are  inclined  backwards, 
are  thick,  and  each  one  presents  a  furrow  in  which  lies  the  ])rim- 
itive  carotid  artery.  The  inner  edge  of  this  furrow  corresponds 
to  the  oesophagus,  while  the  outer  one  forms  a  slight  separation 
between  the  carotid  arteiy  and  internal  jugular  vein. 

The  gland  is  included  in  a  thin  capsule  of  fibro-cellular  tissue, 
wdiicli  comes  to  the  aid  of  the  operator  in  the  work  of  enucleating 
the  gland.  This  capsular  envelope  seems  to  accompany  the 
superior  thyroid  artery,  and,  when  it  reaches  the  gland,  it  expands 
and  forms  the  investing  capsule. 

There  is  often  seen  a  divergence  from  normal  form;  and  the 
diversity  or  variation  may  concern  the  lobes,  the  isthmus,  or  the 
accessory  portion,  named  the  pyramid. 

The  lobes  ma}''  ascend  to  unequal  heights;  one  of  them  ma}'' 
rise  to  the  middle  of  the  thyroid  cartihige,  while  the  other  nearly 
reaches  the  lower  border  of  the  cartilage.  The  lobes  may  be 
developed  unsym metrically  or  irregularly.  They  may  also  be 
replaced  by  lobules  or  fragmentary  portions  which  are  loosely  con- 
nected together.  And  the  thyroid  gland  thus  lobulated,  may, 
according  to  Madelung,  -who  has  carefully  studied  this  abnormal 
form,  assume  various  forms.  Hence,  as  seen,  the  lobes  may  vary 
in  site,  direction  and  in  the  disposition  of  the  component  lobules. 

The  isthmian  portion  may  be  thick,  or  merely  a  thin  band; 
or  narrow,  or  broad.  And  in  height,  it  mav  vary  from  a  half 
inch  to  almost  two  inches  in  elevation;  or  it  may  not  exceed  two 
or  three  lines  in  height. 

From  the  upper  border  of  the  gland  there  often  ascends  a 
pyramid-like  portion;  and  this  is  so  constant  that  the  anatomists, 
Meckel  and  Morgagni,  rarely  saw  it  absent  This  process  may 
arise  from  the  middle  of  the  isthmus;  or  from  the  connection  of 
the  isthmus  w^ith  a  lateral  lobe;  or  it  may  proceed  from  the  lobe 
itself  And  according  as  it  rises  from  tlie  median  line,  or  has 
lateral  origin,  so  it  will  stand  vertical  or  oblique  in  direction. 
The  pyramid  terminates  in  a  fibrous  cord,  which  extends  upwards 
and  is  fastened  to  some  portion  of  the  thyroid  cartilage;  or  it  may 
reach  to  the  hyoid  bone. 

Very  exceptionally,  the  thyroid  gland  consists  of  a  right  and 
left  portion  unconnected  by  the  normal  istlimian  bridge. 


GOITRE.  825 

The  arteries  which  supply  the  gland  are  the  superior  and 
inferior  thyroid  arteries;  and,  in  about  ten  per  cent  of  cases, there 
exists  a  vessel,  entering  from  below,  named  the  middle  thyroid 
artery,  and  which  springs  from  the  arteria  innominata;  this 
vessel  is  named  the  artery  of  Xeubauer.  The  superior  thyroid 
arteries  are  given  off  near  the  commencement  of  the  external 
carotid  arteries;  and,  at  their  beginning,  lie  superficial  in  a 
triangle  formed  by  the  sterno-cleido-mastoid,  digastric  and  omo- 
hyoid muscles;  the  inferior  thyroid  arteries,  at  their  origin  from 
the  subclavian  arteries,  lie  deep ;  and  each  passes  behind  the 
correspoi],ding  primitive  carotid  and  the  sympathetic  nerve;  and 
a  ganglion  of  the  nerve  is  named  thyroid  from  its  position  on  the 
inferior  thyroid  artery.  The  thyroid  arteries  are  normally  of 
C|uateruary  magnitude;  but  in  goitre  they  may  acquire  the  diame- 
ter of  a  finger,  as  was  seen  by  Burns. 

Goitre. — The  thyroid  gland,  or  body,  as  it  is  often  denomi- 
nated, may  be  the  site  of  wounds  and  inflammatory  action;  it  is, 
however,  remarkable  as  the  seat  of  a  growth  named  bronchocele; 
more  commonly  called  goitre.  In  Derbyshire,  in  England,  the 
affection  is  so  frequent  that  it  is  known  there  as  Derbyshire  neck. 
The  Germans  wrongly  name  this  affection  struma.  The  name 
goitre  has  been  borrowed  from  the  French,  and  was  originally 
derived  from  the  Latin  word  guttur,  signifying  throat. 

Goitre  is  an  affection  of  the  thyroid  gland  in  which  there  is 
an  enlargement  of  its  structure;  and  the  latter  maybe  solid  or 
liquid.  Or,  as  Celsus  puts  it,  "there  is  a  tumor,  which  the  Greeks 
name  bronchocele,  that  grows  between  the  skin  and  the  trachea, 
and  which  sometimes  is  composed  of  torpid  flesh ;  and  again,  it 
may  include  some  liquid  similar  to  water  or  honey;  and  some- 
times it  contains  hair  mingled  w'ith  bones." 

This  growth  may  comprise  in  its  development  the  entire  gland; 
or  the  tumor  may  be  confined  to  one  lobe,  as  the  isthmus,  or  the 
pyramidal  portion,  or  to  two  or  more  of  these  parts.  It  may 
vary  in  volume  from  a  small  nodule  that  is  almost  undiscovera- 
ble,  to  one  so  large  that  it  may  occupy  all  the  space  from  the 
chin  to  the  sternum;  and  if  Fischer  and  Mittermayer  are  to  be 
credited,  such  tumor  has  become  pendulous  and  reached  beyond 
the  umbilicus.  The  writer  does  not  insist  on  the  reader  believing 
this;  yet  he  would  record  that  he  has  seen  a  case  in  which  a 
goitrous  tumor  depended  to  the  middle  point  of  the  sternum. 
When  the  tumor  is  symmetrically  developed,  there  is  a  median 
depression  between  the  lateral  lobes.  In  deglutition,  the  goitrous 
63 


S2G  THYROID    GLAND    AND    ITS    AFFECTIONS. 

gi'owtli  makes  excursions  upwards  and  downwards;  and  when 
the  tumor  is  not  large,  in  the  act  of  swallowing,  there  will  be 
observed  a  well-marked  fossa  in  the  middle  line  of  the  neck. 
This  hollow  will  be  less  in  proportion  to  the  development  of  the 
isthmus.  When  the  goitre  is  developed  laterally,  it  carries  the 
carotid  artery  forwards  and  laterally;  indeed,  in  such  a  case,  the 
artery  will  be  found  lying  under  the  skin,  a  long  distance  from 
the  median  l;ne.  This  lateral  displacement  of  the  vessels  is  an 
anatomical  fact  of  the  utmost  importance  in  the  surgical  treat- 
ment of  goitre;  and  it  must  not  be  forgotten  in  the  operation  of 
thjTotomy. 

In  this  lateral  shifting  of  vascular  location  the  internal  jugular 
vein  also  shares.  In  one  case,  however,  seen  by  the  writer,  the 
carotid  artery  was  not  displaced,  but  the  internal  jugular  vein 
was  uplifted  and  lay  flattened  as  a  blue  ribbon  over  the  goitrous 
tumor,  which  had  developed  from  the  left  lobe  of  the  gland  and 
grown  only  towards  the  left,  carrying  the  vein  with  it;  a  perilous 
anomaly. 

In  the  development  of  the  goitre,  its  anatomical  structure  will 
be  determined  by  the  element  which  j)redominates  in  the  growth  : 
thus  according  as  the  fibrous,  vascular,  or  glandular  tissue  is  pre- 
dominantly developed,  so  the  goitre  is  distinguished  as  fibrous^ 
vascular,  cystic,  or  follicular  goitre.  Ecker,  who  has  made  a 
study  of  goitre,  published,  in  1S45,  the  following  classification: 
vascular,  cystic  and  glandular. 

The  vascular  species  arises  from  congestive  hyperfemia  of  the 
gland,  often  due  in  the  female  to  parturient  elfort:  also  such  con- 
gestion may  be  due  to  the  changes  which  attend  puberty;  and 
such  afflux  may  arise  from  menstruation  and  pregnancy.  From 
this  congestion,  the  capillaries  and  smaller  arteries  dilate  and 
become  varicosed,  and  ultimately  rupturing,  Ijlood  is  effused  into 
the  parenchyma  of  the  gland.  This  extravasated  blood  becomes 
the  starting-point  of  the  cyst;  and  in  the  formation  of  the  cyst 
the  colored  cells  perish  and  become  absorbed,  or  are  converted 
into  other  forms  of  organic  matter,  which  may  be  crystalline  or 
amorphous.  Or  if  the  blood  be  considerable  in  quantity,  then  its 
fibrinous  content  may  be  deposited  on  the  containing  wall,  and 
thus  a  cyst  is  formed. 

The  vessels  sometimes  undergo  calcification,  and  this  change 
favors  rupture  of  the  walls;  and  some  even  claim  that  such 
calcification  precedes  and  occasions  h^^persemia.  The  calcified 
material  may  form  calcareous  concretions.     The  chalky  matter 


GOITRE.  827 

may  be  precipitated  in  stratified  form;  and  also  other  exuded 
matter  may  be  arranged  in  layers.  The  calcareous  material 
for  such  calcification  is  thought  to  be  derived  from  the  lime- 
containing  water  used  by  the  subject.  In  the  third  species,  named 
glandular,  since  all  the  constituents  of  the  gland  concur  in  its 
formation,  the  tumor  is  found  filled  with  gelatinous,  or  albumin- 
like material.  If  such  goitrous  structure  be  incised,  it  presents 
a  yellow  stroma  in  which  bluish,  diaphanous  masses  are  seen; 
and  these  pellucid  masses  may  have  any  A^olume  from  that  of  a 
pin's  head  to  that  of  a  child's  head.  The  content  resembles  boiled 
sago.  When  such  content  is  in  large  amount,  it  crowds  on  and 
renders  denser  the  surrounding  glandular  structure;  and  this 
compression  may  be  such  as  to  quite  obliterate  all  traces  of  the 
true  structure.  Ecker's  explanation  of  the  origin  of  tliis  colloid 
or  gelatinous  tumor  is,  that  the  efferent  lymphatic  vessels  fail  to 
remove  the  matter  formed  in  the  glandular  vessels;  and  he  com- 
pares it  to  a  cyst  from  retention.  The  vessels  remaining  after 
such  a  tumor  has  formed,  lacking  their  normal  support,  burst 
and  add  blood  to  the  colloid  content. 

Rokitansky,  the  veteran  pathologist  of  A^ienna,  whose  study  of 
disease  as  revealed  in  the  dead-house  has  been  surpassed  by  no 
individual,  claims  that  the  different  kinds  of  goitre  are  derived 
from,  and  referable  to,  one  common  genus,  viz.,  the  vascular. 
From  this  common  class,  according  to  the  course  followed  in  the 
evolution  of  the  tumor,  it  may  be  named  exogenous  or  endoge- 
nous. In  the  exogenous  class  are  comprised  those  forms  in  which 
the  development  is  excentric,  or  from  within  outwards.  In  the 
endogenous  type,  the  cells  or  compartments  grow  through  the 
development  of  smaller  growths  within  the  primary  one.  If  a 
tumor  of  this  type  be  opened,  the  secondary  growths  can  be  seen 
adhering  to  the  parent  wall.  In  this  form  vessels  can  be  seen 
passing  from  the  primary  wall  to  the  secondary  endogen.  And 
when  such  a  growth  has  reached  full  maturity,  it  becomes  sterile; 
and  then  neither  nucleated  nor  glandular  elements  can  be  found 
within  it.  This  stage  is  the  terminal  one  of  the  goitre;  and  such 
a  growth  corresponds  in  character  to  cysts  in  other  regions  of  the 
body. 

Returning  from  this  morphological  history  of  goitre,  and  utiliz- 
ing the  facts  here  learned,  a  practical  and  compendious  division 
of  the  subject  is  into  two  classes:  solid  and  liquid  or  semi-liquid. 

In  the  solid  species  the  constituents  are  both  multiplied  and 
enlarged.     Such  a  tumor  has  the  solid  feel  of  muscular  tissue;  it 


82S  THYROID    ULAND    AND    ITS    AFFECTION'S. 

is  slightly  elastic,  yet  on  percussion,  it  yields  no  impulse  of  fluc- 
tuation. It  is  painless;  and  even  when  strongly  compressed  there 
is  awakened  only  a  dull  pain,  or  nnj)leasant  feeling.  When  the 
tumor  is  displaced,  its  connection  with  the  air-passages  is  shown 
in  this,  that  the  air  canal  obeys  the  movements  of  the  goitre. 
The  overlying  skin  is  of  natural  hue,  and  has  but  little  or  no 
attachment  to  the  goitre.  If  the  solid  goitrous  growth  be  split 
open,  an  appearance  akin  to  that  of  the  normal  glandular  struc- 
ture will  be  presented  to  the  eye;  and  such  section  on  ]>ressure 
will  yield  glandular  elements,  viz.,  vesicles  and  a  syrup-like  fluid 
Sometimes  in  such  tumors,  alteration  of  tissue  will  be  found 
which  denotes  the  transition  to  the  cystic  formation. 

In  the  second  general  form,  the  constituent  elements  on 
examination  are  found  multiplied  and  enlarged.  Vesicles  diff'er- 
ing  in  volume  will  be  discovered;  and  these  contain  a  content 
Avhich  is  liquid,  or  gelatinous  in  character.  Sucii  a  goitre  pre- 
sents analogy  to  the  multilocular  cyst  of  the  ovary.  If  the 
examination  be  made  at  a  later  period  of  development,  larger 
cavities  containing  cystic  material  will  be  found,  which  have 
arisen  from  the  confluent  fusion  of  a  number  of  smaller  cavities. 
And  by  a  continuation  of  growth,  degeneration  and  fusion,  tiie 
multilocular  subcysts  are  transformed  into  one  large  cystic  cavit}-. 
Or  instead  of  one,  the  tumor  may  contain  two  or  more  separate 
cystic  compartments. 

The  content  of  the  goitrous  cyst  presents  several  varieties.  In 
a  few  ca.ses  seen  by  the  writer,  it  was  a  transparent  fluid  of 
remarkable  clearness;  more  often,  however,  such  content  is  turbid, 
and  on  the  walls  of  the  cavity  there  will  be  found  a  detritus, 
which  is  the  remnant  of  clotted  blood.  And  when  shaken  up, 
the  liquid  content  is  similar  to  the  lees  of  wine.  Again,  the  con- 
tent may  resemble  semi-liquid  gelatine,  discolored  with  pigmen- 
tary' matter,  and  this  may  be  of  different  degrees  of  fluidity. 
Sometimes  a  steatomatous  or  adii)Ose  material  is  found  in  the 
cyst.  During  the  development  of  the  cyst,  the  blood-vessels  in 
the  distending  walls  may  be  ruptured;  and  thus  blood  is  added 
to  the  cystic  content;  or  one  of  the  compartments  may  be  quite 
filled  with  blood,  of  which  the  coagulum  remains  and  becomes 
a  permanent  constituent. 

Besides  the  content  mentioned,  sometimes  there  are  found 
osseous  or  calcareous  concretions,  either  alone  or  along  with 
liquid  content. 

A  form  of  goitre  not  very  unusual  is  that  in  which  the  exces- 


GOITRE.  829 

sive  development  concerns  the  vessels;  the  arteries  enlarge  enor- 
mously, so  that  they  constitute  the  chief  component  of  the  tumor; 
and  in  such  a  case,  the  tumor  consists  of  a  mass  of  aneurysmal 
varices.  If  this  tumor  be  grasped  in  the  hand,  there  will  be  felt 
in  it  a  pulsating  thrill,  a  movement  and  expansion  synchro- 
nous with  the  pulse.  The  aneurysmal  goitre,  though  it  attains 
less  dimensions  than  the  cystic  form,  yet  the  former  through  its 
vibratile  motion  and  buzzing  sound,  becomes  a  source  of  great 
annoyance  to  the  patient. 

Maunoir,  of  Geneva,  claims  that  frequently  the  so-called  goi- 
trous cyst  is  not  of  thyroid  origin;  and  he  names  them  hydrocele 
of  the  neck.  Tillaux  concedes  that  this  ma}'  be  so,  exceptionally, 
viz.,  that  it  may  arise  in  the  bursse  of  the  prse-laryngeal  muscles; 
also  a  lymphatic  gland  of  similar  site  may  simulate  goitre;  yet 
Tillaux  has  found  in  his  dissections  that  in  doubtful  cases  there 
could  be  traced  a  connection  between  the  thyroid  gland  and  the 
tumor;  and  such  connection  was  often  in  the  form  of  a  narrow,, 
elongated  pedicle.  And  he  formulates  as  an  anatomical  axiom, 
that  in  those  cases  in  which  a  tumor  located  in  the  sub-hyoid 
region  ascends  and  descends  during  the  movements  of  degluti- 
tion, it  almost  always  originates  in  the  thyroid  gland. 

Trained  digital  palpation  can  often  recognize  the  nature  of 
the  goitrous  content;  yet,  to  arrive  at  absolute  certaint}^  the  hypo- 
dermic syringe  should  be  used,  and  some  of  the  content  with- 
drawn. The  determination  of  the  nature  of  the  goitrous  content,, 
if  interesting  in  surgical  pathology,  is  yet  more  so  to  the  practical 
surgeon,  since  it  indicates  the  course  to  be  pursued  in  the  treat- 
ment of  the  disease. 

The  goitrous  tumor  when  small,  and  seated  high  in  the  neck, 
gives  the  patient  but  little  inconvenience;  yet  when  it  becomes 
voluminous,  and  even  when  diminutive,  if  seated  near  the  ster- 
num, it  gives  trouble  through  compression. 

Bilz,  in  1850,  studied  the  changes  of  form  and  position  of  the 
trachea  which  such  pressure  can  produce,  and  found  that  the 
trachea  might  be  misplaced  laterally;  also  the  tracheal  canal 
may  be  flattened,  or  converted  into  a  triangular,  prismoidal  form. 

Compression  acts  most  deleteriously  when  the  tumor  grows 
inwards  rather  than  outwards;  or  when  it  is  deep-seated  and  rests 
closely  on  the  important  structures  which  traverse  the  neck. 
Such  pressure  can  narrow  the  tracheal  and  sesophageal  canals, 
and  can  disturb  the  function  of  the  recurrent,  sympathetic,  pneu- 
mogastric  and  phrenic  nerves. 


830  THYROID    GLAND    AND    ITS    AFFECTIONS. 

Bonnet,  wlio  has  studied  the  functional  disturbance  resulting 
from  the  mechanical  action  of  such  tujuors  on  contiguous  struc- 
tures, finds  that  a  small  goitrous  growth  seated  at  the  junction  of 
tlie  neck  and  thorax,  can  cause  dyspnoea,  numbness  in  the  arms, 
and  aphonia  or  impaired  voice.  And  such  compression  is  aug- 
mented when  the  tumor  glides  behind  the  clavicle,  or  the  sternum. 
"When  the  trachea  is  thus  narrowed,  the  entering  air  expands 
the  trachea  above  the  constriction;  and  the  air  returning  from  the 
lungs,  being  obstructed  in  its  exit,  causes  abnormal  expansion  of 
the  air-passages  below  the  constriction;  and  then,  as  Bilz  has 
found,  an  emphysematous  condition  of  the  lungs  is  induced.  In 
some  cases,  the  sterno-cleido-mastoid  muscle,  when  uplifted  or 
stretched  by  the  goitre,  may  be  the  chief  factor  in  the  pressure; 
so  much  so  that  Bonnet,  to  get  relief,  severed  the  muscle. 

Rose,  in  the  Archivfur  Klinische  Chirurgie,  in  1878,  published 
his  observations  of  the  mechanical  effects  of  goitre  on  the  trachea. 
He  finds  that  alteration  occurs  about  the  first  tracheal  ring. 
Patients  unconsciously  correct  this  curve  or  inflection;  but  when 
the  subject  is  ana3sthetized,  the  inflection  returns,  and  respiration 
may  thus  be  seriously  interrupted.  Rose  found  cases  in  which 
the  trachea  was  maintained  patent  through  the  goitre  surround- 
ing it  on  all  sides;  in  such  cases,  the  removal  of  the  tumor  should 
be  preceded  by  tracheotomy. 

Kaufmann,  in  1883,  describes  a  form  of  goitre,  which  from  its 
situation  he  names  the  retro-pharyngeal  and  retro-oesophageal 
goitre,  and  which  interferes  with  voice,  breathing,  and  swallowing. 
The  goitre  may  be  unilateral  or  bilateral ;  and  in  the  former  case, 
it  can  only  be  moved  towards  one  side.  The  remedy  in  such  a 
case  is  extirpation. 

In  1887,  Heise  reported  three  cases  of  goitrous  tumor  within 
the  air-passages;  the  growth  was  attached  to  the  posterior  wall  of 
the  larynx  and  trachea,  and  was  not  connected  with  the  thyroid 
gland.  The  subjects  were  young,  and  the  tumor  caused  dyspnoea. 
The  growths  were  removed  by  laryngo-tracheotomy.  Streckeisen 
saw  such  a  growth  seated  higher,  within  the  arch  of  the  hyoid 
bone. 

Having  concluded  the  description  of  the  anatomical  char- 
acteristics and  the  symptomatic  phenomena  of  goitre,  a  consider- 
ation of  its  causation  is  next  in  order  :  this  subject  has  occupied 
the  pens  of  many  theorists  and  also  many  practical  observers. 
It  is  a  polenical  field  beset  with  diverse  and  antagonistic  opin- 
ions, in  which  the  only  points  settled  beyond  contest  are  that 


GOITRE.  831 

goitre  has  its  favorite  topographical  habitats,  and  in  most  cases 
occurs  in  the  female;  and  further  that  it  is  in  some  way  asso- 
ciated with  the  generative  function. 

In  the  south  of  Europe  there  is  a  popular  belief  that  the  sex- 
ual act  enlarges  the  previous  virginal  neck  ;  and  allusion  to  this 
is  in  the  line  of  Catullus;  non  hesterno  poterit  collum  circumdare 
filo.  And  Malgaigne  mentions  that  the  watchful  matron  tests  the 
moral  character  of  girls  between  fifteen  and  twenty  years  of  age 
by  placing  the  two  ends  of  a  measuring  cord  between  the  incisor 
teeth,  and  then  passing  the  loop  over  the  head;  such  a  close-fitting 
loop  can  contain  the  neck  of  the  intact;  but  it  will  not  include 
the  neck  of  the  other  class.  In  these  admeasurements  the  male's 
neck  seems  to  have  been  forgotten. 

The  straining  efforts  of  the  female  in  parturient  labor  act  espe- 
cially on  the  thyroid  gland,  which  becomes  for  the  occasion  a 
reservoir  in  which  the  blood  takes  temporary  refuge;  and  there 
finally  results  a  permanent  enlargement  of  the  part;  the  writer 
has  known  several  cases  of  goitre  which  arose  in  this  way.  As  a 
rule,  goitre  of  puerperal  origin  is  bilateral,  and  does  not  attain 
large  dimensions.  Suppression  of  the  menses  is  sometimes  coin- 
cident with  development  of  the  thyroid  gland. 

Heredity  is  a  disposing  agency.  And  the  disease  has  devel- 
oped in  the  foetus;  and  to  such  dimensions  that  it  caused  suffo- 
cation of  the  new-born. 

The  disease  often  appears  in  the  subject  of  fair  complexion 
and  lymphatic  temperament.  The  scrofulous  subject  is  likewise 
disposed  to  goitre.  And  this  is  so  usual,  that  it  has  influenced 
the  nomenclature  of  goitre:  since  goitre  is  universally  designated 
struma  by  the  German  writer.  That  this  name  is  appropriate, 
the  writer  will  not  concede;  though  it  may  be  somewhat  justified, 
when  a  writer  of  such  eminence  as  Bazin  says  that,  in  nearly  all 
cases  of  goitre,  he  has  found  other  symptoms  of  the  scrofulous 
constitution.  Hypertrophy  of  the  thj^roid  body  seems  to  be 
cognate  to  scrofula,  in  the  same  manner  as  the  hypertrophy  of 
the  thymus  gland  is  related  to  syphilis. 

Occupation  in  which  there  is  laborious  and  continued  mus- 
cular effort,  favors  thyroid  hypertrophy. 

Besides  the  agencies  enumerated  which  figure  in  the  causa- 
tion of  goitre,  there  are  others  of  a  more  obscure  nature,  which 
have  claimants  among  surgical  and  medical  writers. 

The  fact  that  the  disease  is  endemic,  in  fact,  pandemic  in 
some  geographical  regions,  has  led  to  a  search  in  those  places,  for 


832  THYROID    GLAXD    AND    ITS  AFFECTION.S. 

the  disposing-  cause.  Tlie  countries  iu  whicli  goitre  prevails  are 
Derbysliire,  in  England,  the  warm  countries  of  the  Tyrol,  the 
Alps,  and  especially  the  Alpine  region  of  Isere,  Savoy  and  Pied- 
mont, in  southeastern  France.  In  the  vicinity  of  Uriage,  in  the 
southeast  of  France,  visited  by  the  writer,  there  is  a  village  in 
which  goitre  and  cretinism  in  amiciible  sovereignty  have  aljsolute 
control;  a  region  in  which  nature,  having  placed  her  sublimest 
pictures,  afterwards,  in  mocking  ironv,  formed  humanity  dwarfed, 
deformed  and  imbecile. 

The  cause  of  this  endemic  goitre  has  been  sought  for  in  the 
air,  water,  and  food  on  which  the  inhabitants  subsist.  The  use 
of  water  from  the  melted  snow  has  been  assigned  as  a  cause; 
also,  the  presence  of  dissolved  magnesian  limestone  in  the 
w'ater  has  been  urged  as  the  cause;  and  much  proof  in  favor  of 
this  agency  has  been  brought  forward.  Bromine,  lithium  and, 
recently,  fluorine  have  been  given  place  as  causal  agencies.  A 
dog  fed  by  Maumon^  on  fluoride  of  sodium  for  four  months,  devel- 
oped a  general  tumefaction  of  the  neck.  The  intemperate  use  of 
ice-water  has  been  offered  as  one  of  the  causes  of  goitre. 

Chatin,  in  1852,  announced  a  new  theory  in  regard  to  the 
origin  of  the  disease;  he  referred  the  origin  of  goitre  to  the 
absence  of  iodine  in  the  air,  water  and  food  used  by  the  subject. 
To  confirm  this  hypothesis  he  made  a  long  journey  in  the  Jura 
Alps,  Lombardy  and  other  regions  in  which  the  affection  was 
prevalent,  and  examined  the  air,  water  and  food  chemically. 
Though  he  found  in  Lombardy  facts  which  were  in  discord  with 
his  doctrine,  yet  these  seemed  insufficient  to  alter  his  opinion 
that,  where  goitre  prevails,  it  is  due  to  the  ab.sence  of  iodine; 
and  his  inference  is  that  in  non-goitrous  countries,  the  inhab- 
itants continually  use  enough  iodine  to  counteract  the  develop- 
ment of  the  disease.  Chatin's  doctrine  is  accepted  by  Moleschott, 
in  his  noted  work  entitled  the  "Circulation  of  Life."  The  author 
has  observed  facts  at  variance  with  Chatin's  theory;  on  the 
Isthmus  of  Panama,  on  the  western  coast  of  Nicaragua  and 
Mexico,  he  has  observed  cases  of  goitre  in  persons  who  had 
always  breathed  the  air  from  the  ocean,  impregnated  with  iodine. 
A  similar  observation  has  been  made  among  the  inhabitants  of 
California,  among  whom  the  writer  has  seen  several  cases  of  the 
disease,  in  both  males  and  females.  Hence  the  theory  of  Chatin 
is  untenable;  or  if  it  contains  a  grain  of  truth,  the  most  that  can 
be  granted  to  it  is  to  hold  a  conjectural  place  among  the  causal 
agencies  of  goitre. 


GOITRE. 

In  a  search  for  the  causation  of  goitre,  some  claim  that  there 
exists  a  mutual  relation  between  the  parotid  and  thyroid  gland; 
viz.,  that  where  the  parotis  remains  in  a  state  of  inertia  from 
non-use,  as  in  the  case  of  shejDherds  who  chew  but  little,  and 
consequently  there  is  but  slight  excretion  of  saliva,  the  thyroid 
gland  enlarges;  but  on  the  contrary,  those  who  live  on  vegetable 
food,  and  hence  masticate  freely,  are  exempt  from  goitre. 
Hence,  for  prophylaxis  and  cure,  Grynfelt  advises  the  use  of  food 
that  demands  active  use  of  the  muscles  of  mastication.  The 
author  has  had  under  his  observation  two  cases  which  militate 
against  this  theor}^  viz.,  two  persons  who  in  infancy  through 
cicatricial  contraction  of  the  structures  of  the  side  of  the  face  lost 
the  power  of  using  the  lower  jaw;  in  these  cases  there  was  no 
thyroid  enlargement  observable. 

In  1860  Collin  reported  an  epidemic  of  goitre  which  occurred 
in  a  body  of  French  troops  stationed  at  Brian^on,  and  in  another 
body  stationed  at  Clermont.  At  Briancon,  the  disease  appeared 
suddenly  in  a  number  of  men.  Collin,  who  had  the  surgical  care 
of  these  soldiers,  referred  the  origin  of  the  disease  to  the  slight 
elevation  of  the  place  above  the  level  of  the  ocean,  in  consequence 
of  which  the  air  was  rarefied,  and  produced  difficulty  of  breath- 
ing; thus,  he  claimed  that  congestion  of  the  gland  arose,  and 
that  this  was  promoted  by  the  soldiers'  uniform,  which  caused 
constriction  of  the  neck  and  chest.  The  exercise  of  carrying 
burdens  up  the  hill,  also,  contributed  to  such  congestion. 

In  the  regions  of  the  Alps  where  the  disease  is  pandemic,  that 
the  disease  depends  on  some  local  cause  or  causes  is  indisputable 
from  the  fact  that,  besides  man,  numerous  domestic  animals 
become  also  the  subjects  of  the  disease.  Thus,  Baellarger  saw 
goitre  in  the  horse,  the  dog,  the  cow,  the  sheep,  the  goat,  the  hog, 
and  especially  in  the  mule.  And  in  such  regions  persons  unaf- 
fected wdth  the  disease,  coming  and  sojourning,  may  become  the 
subjects  of  goitre;  and  also  in  those  in  whom  the  disease  has  com- 
menced to  appear,  should  they  leave  the  locality,  the  disease 
recedes. 

In  those  regions  in  which  goitre  prevails,  especially  in  certain 
mountainous  districts  of  Switzerland,  there  also  prevails  a  con- 
stitutional disease  denominated  cretinism;  and  in  many  cases 
goitre  and  cretinism  occur  in  the  same  individual. 

Cretinism  is  a  disease  in  which  there  is  a  general  arrest  of 
development  of  the  subject.  There  is  cranial  deformity  in  which 
the   frontal   and   parietal   eminences   are  unusually  prominent, 


834  THYROID   GLAND    AND    ITS    AFFECTIONS. 

and  ossification  is  retarded,  or  imperfect.  The  teetli  are  irregular 
in  formation  and  position,  and  second  dentition  is  wanting,  or 
imperfect.  Tlie  muscles,  tendons  and  aponeurotic  fasciie  are  ill 
formed;  and  as  result,  the  subject  is  liable  to  hernia.  The 
functions  of  digestion  and  assimilation  are  imperfectly  performed, 
and  there  may  be  pyrosis,  ill  appetite  or  inordinate  voracity. 
The  pulse  is  often  small,  and  too  frequent.  The  patient  is 
emaciated,  the  skin  loose  and  flabby,  and  the  tissues  are  cedem- 
atous.  The  generative  faculty  is  feeble,  perverted,  or  lost. 
Melancholy,  hysteria,  mania  and  dementia  are  present.  The 
intellect  is  clouded,  narrowed  or  nullified  to  complete  idiocy,  so 
that  the  mentality  of  the  cretin  is  reduced  to  a  few  fragmentary 
traces  which  might  be  designated  instinctive  rather  than 
rational.  And  this  dwarfed  human  parody  may  have  as  an 
additional  touch  of  degeneration,  a  goitrous  neck;  and  so  often 
is  this  true,  that  there  must  be  an  intimate  consanguinity  between 
the  causal  agencies  of  cretinism  and  goitre. 

Perhaps  the  goitrous  enlargement,encroaching  on  the  adjacent 
vessels  and  nerves,may  arrest  the  growth  of  the  brain  and  disturb 
the  functions  of  the  heart  and  lungs;  and  in  the  child  such 
deranging  influence  would  promote  general  corporeal  degenera- 
tion, viz.,  cretinism,  or  something  akin  to  it. 

Treatment. — This  may  be  placed  under  three  heads:  prophy- 
lactic and  restraining,  medical  and  surgical  treatment. 

A  })reeaution  of  great  prophylactic  value,  when  practicable, 
is  the  removal  of  the  patient  from  the  region  in  which  he  is 
exposed  to  the  external  influences  which  promote  the  goitrous 
growth.  Kneading  and  rubbing  the  tumor  should  be  practiced 
so  as  to  awaken  a  counter-action  to  the  morbid  processes  occurring 
in  the  gland;  thus,  a  healthy  cell-metabolism  and  return  to 
normal  structure  will  be  promoted;  and  though  the  goitrous  tissue 
may  not  be  made  to  disappear,  or  even  recede,  yet  further  prog- 
ress in  the  direction  of  glandular  degeneration  may  thus  be 
arrested. 

As  a  means  of  restraining  growth,  a  cravat  or  bandage  about 
the  neck  has  been  used.  Such  a  compressive  bandage  might  be 
made  of  elastic  material.  There  is  a  serious  objection  to  this 
repressive  treatment,  since,  thereby ,the  growth  is  crowded  against 
the  cervical  vessels,  and  thus  congestion  of  the  head  is  maintained; 
and  a  further  fault  is  that  a  growth  which  is  compressed  back- 
wards is  caused  to  grow  in  that  direction,  and  to  deform  the 
tracheal  canal,  and  also  to  insinuate  itself  between  the  windpipe 


GOITEE.  835 

and  the  oesophagus;  or  else  to  include  and  to  encircle  these 
passages. 

Medical  Treatment. — In  1S20  Coindet  announced  the  successful 
treatment  of  goitre  by  means  of  iodine.  Other  medicinal  agents 
have  since  been  advised;  3'et  none  have  yielded  the  satisfactory 
results  which  have  been  obtained  from  iodine.  This  agent  may 
be  used  externally,  parenchymatously,  or  it  may  be  given  by 
the  mouth, 

"When  externally  employed,  iodine  may  be  in  the  form  of  the 
simple  tincture  of  iodine,  or  the  compound  tincture;  or  the  simple 
or  compound  ointment  of  iodine  may  be  used.  The  solution  of 
iodine  in  glycerine  or  collodion  has  been  employed.  The  simple 
or  compound  tincture  of  iodine  is  applied  by  means  of  a  brush; 
a  number  of  coats  are  to  be  applied  daily.  "When  the  scarf-skin  is 
loosened,  this  must  be  removed,  and  the  painting  renewed  on  the 
freshened  surface.  This  treatment  to  be  effective,  must  be  con- 
tinued for  a  long  period:  many  months,  at  least.  And  as  the 
favorable  result  is  so  slowly  obtained  that  it  is  nearly  impercep- 
tible, the  patient  and  surgeon,  in  most  cases,  finally  lose  hope  of 
reaching  a  cure  in  this  way;  and  the  former  is  hastened  to  such 
a  conclusion  by  the  pain  with  which  he  is  harassed  by  the  irri- 
tating action  of  the  iodine.  Instead  of  using  the  tincture  of 
iodine,  the  writer  prefers  a  solution  in  collodion  :  thus  the  action 
is  hastened,  and  the  compressive  action  of  the  collodion  is  added 
to  the  specific  action  of  the  iodine.  For  this  purpose  let  the 
following  compound  be  used: — 

^.    Collodii .?ij 

lodi  puri gr.  xij 

Potassii .  lodidi ^ss 

Misce. 

Let  a  number  of  coats  be  painted  on  and  around  the  goitrous 
enlargement.  The  collodion  forms  a  constricting  capsule  about 
the  tumor;  and  the  included  derm  is  irritated  or  vesiccated,  so 
that  the  iodine  penetrates  the  tissues.  After  this  crust,  including 
the  epiderm,  has  become  loosened,  it  should  be  detached  and  a 
new  coat  applied.  To  render  this  application  less  painful,  the 
fresh  surface  can  be  cocainized. 

Iodine  in  combination  with  mercury,  has  been  used  in  the 
form  of  an  ointment,  which  is  made  as  follows: — 

IjL.    Hydrarg.  Biniodidi ji 

Adipis grs.  xxx 

Misce. 


83G  THYROID    GLAND    AND    ITS    AFFECTIONS. 

A  portion  of  this  is  to  be  rubbed  daily  on  the  tumor,  for  some 
minutes,  and  then  the  part  must  be  exposed  to  the  rays  of  the 
sun.  This  treatment  was  introduced  by  a  layman  in  the  East 
Indies,  and  afterwards,  adopted  and  used  in  some  thousands  of 
cases  of  goitre,  with  beneficial  effect. 

By  a  long  use  of  the  iodine  externally  applied  in  one  of  the 
ways  mentioned,  the  goitrous  affection  may  be  checked  in  its 
growth,  and,  perhaps,  made  to  recede;  yet  the  employment  of 
the  remedy  hypoderraically  is  less  circumstantial,  and  is  more 
prompt  and  more  effective  in  action.  The  hypodermic  use  of 
iodine  in  the  treatment  of  goitre  was  announced  in  1853  by 
Woerner,  whose  observations  were  made  on  cases  treated  in  the 
surgical  clinic  of  Tubingen.  Tiiese  cases  were  of  the  cystic  form, 
and  the  work  was  done  as  follows:  by  means  of  a  trocar  the 
liquid  content  was  evacuated,  and  then,  into  the  emptied  sack 
there  was  injected  from  one  to  two  drachms  of  pure  tincture  of 
iodine,  which  was  permitted  to  remain.  About  one-half  of  the 
cases  were  cured,  while  the  others  remained  uncured.  After  the 
injection,  a  burning  feeling  was  experienced  in  the  sack;  the  lat- 
ter soon  refilled,  but  in  a  month  or  two.  the  tumor  began  to  lessen, 
and  continued  to  do  so  until  a  cure  was  effected.  In  18G7,  Luton 
published  a  pa{)er  on  the  same  subject,  in  which  he  claimed  to 
have  taken  the  initiative.  He  injected  the  tincture :  and  accord- 
ing to  the  volume  of  the  tumor,  and  the  number  of  its  lobes, 
more  or  less  was  employed;  and  the  amount  thus  used  varied 
from  one  scruple  to  four  scruples.  The  injection  was  followed 
by  a  burning  pain,  and  if  a  lateral  lobe  was  the  part  attacked, 
then  the  pain  extended  upwards  towards  the  side  of  the  head^ 
and  downwards  to  the  shoulder.  The  injected  part  swelled,  and 
it  remained  swollen  and  painful  for  some  days.  The  patient 
perceives  the  taste  of  iodine  in  his  mouth,  and  the  agent  can  be 
detected  in  the  urine.  iVfter  this  the  tumor  begins  to  diminish, 
yet  the  curative  results  are  not  fully  realized  until  after  the  lapse 
of  some  months.  Hence,  Luton  says,  the  injections  need  not  be 
often  repeated.  After  each  injection,  one  should  wait  until  its 
action  has  become  exhausted.  Tlie  induration  arising  results 
from  the  coagulation  of  the  albumen  from  contact  with  the 
iodine. 

This  interstitial  treatment  gave  the  best  results  in  the  soft 
and  diffused  species.  The  polycystic  species  is  also  thus  curable ; 
and  Luton  and  Monod  found  that  it  was  not  necessary  to  first 
empty  the  sack;  the  cystic  content  serves  as  an  excellent  medium 


GOITRE.  837 

by  which  the  iodine  is  brought  in  contact  witli  the  walls  of  the 
goitre.  Large  goitres  can  thus  be  treated  with  a  fair  probability 
that  the  volume  will  be  diminished,  though  the  tumor  will  not 
wholly  vanish.  In  the  multilocular  species,  the  injection  into 
one  section  has  caused  general  lessening;  yet  in  such  it  is  better 
to  attack  several  lobes.  This  interstitial  treatment  is  not  suited 
to  the  aneurysmal  species  of  goitre. 

Luton  reports  forty-eight  cases  of  goitre  thus  treated;  of  these 
thirty-two  were  completely  cured;  twelve  were  made  better,  and 
in  the  remainder,  no  benefit  was  derived  from  the  treatment. 
Subsequent  work  done  by  this  plan  of  treatment  has  further 
demonstrated  its  utility.  Where  ill  results  followed  the  use  of 
iodine  thus  employed,  they  were  not  more  severe  than  those 
which  occur  after  the  use  of  the  agent,  when  given  by  the  mouth. 
The  instrument  used  for  this  work  was  the  syringe  of  Pravaz,  or 
that  employed  for  the  ordinary  subcutaneous  injection. 

In  1872,Schwalbe  reported  in  Virchow's  Archives  one  thousand 
cases  of  goitre  treated  by  the  interstitial  injection  of  remedies. 
He  uses  the  hypodermic  syringe  as  a  diagnostic  aid  to  determine 
whether  the  tumor  be  cystic,  vascular,  glandular  or  fibrous;  from 
the  cystic,  liquid  content  escapes;  from  the  glandular  and  fibrous, 
nothing  escapes;  while  blood  escapes  from  the  vascular.  He  used 
a  syringe  somewhat  larger  than  that  of  Pravaz;  and  a  point  that 
is  conical  is  better  than  one  which  is  ground  down  on  one  side, 
since  the  latter  can  bend  or  break. 

The  treatment  is  not  free  from  danger;  in  one  case,  after  an 
injection,  the  patient  complained  of  prickling  in  the  arm  and  leg; 
convulsions  soon  followed,  ending  in  death.  In  many  cases  pain 
radiated  along  the  course  of  the  adjacent  nerves. 

Schwalbe,  for  a  time,  used  the  tincture  of  iodine;  later,  believ- 
ing that  alcohol  was  the  chief  agent  in  the  work,  he  used  this 
alone,  and  obtained  satisfactory  result.  The  quantity  used  was 
from  ten  drops  to  a  drachm.  The  injections  were  repeated  at 
intervals  of  from  three  to  eight  days.  Along  with  these  injec- 
tions, fifteen  grains  of  iodide  of  potassium  were  taken,  daily,  by  the 
mouth.  To  be  sure  that  a  blood-vessel  was  not  penetrated, 
Schwalbe,  after  inserting  the  point,  let  it  remain  a  short  time,  in 
order  to  determine  whether  blood  would  escape. 

Instead  of  the  tincture  of  iodine.  Fowler's  solution  of  arsenic 
has  been  used.  In  1882,  Griinmach  reported  the  treatment  of 
nearly  one  hundred  cases,  by  the  subcutaneous  injection  of  the 
tincture  of  iodine.     He  diluted  the  remedy  with  an  equal  amount 


838  THYIIUII)    GLAND    AND    ITS    AFFtCTlOXS. 

of  water,  and  of  this  he  injected  a  half  Pravaz  syriugeful,  two 
or  three  times  a  week. 

A  third  mode  of  treatment  is  the  administration  of  remedies 
by  tiie  mouth;  thus  iodine,  arsenic  and  tlie  nmriate  of  lime  may 
be  given.  Yet  such  indirect  route  of  reaching  the  tumor  should 
not  wholly  be  trusted  to  ;  it  sliould  be  combined  witli  tlie  ender- 
mic  or  inierstitial  use  of  one  of  the  anti-goitrous  remedies;  thus  an 
attack  being  made  from  within  and  without,  the  treatment 
becomes  more  effective. 

Electrolysis  as  an  anti-goitrous  treatiuent  has  its  advocates; 
the  writer  has  observed  cases  in  which  the  use  of  the  constant 
current  not  only  retarded  the  growth  but  caused  diminution  of 
the  existing  volume;  and  since  this  method  commends  itself  by 
its  painlessness  and  simplicity,  it  may  be  tried.  Both  the  con- 
stant and  interrupted  currents  may  be  employed;  yet  the  gal- 
vanic or  constant  current  has,  from  experience,  received  greater 
sanction. 

Should  the  means  of  treatment  which  have  been  enumerated 
prove  unsuccessful,  then  a  resort  may  be  had  to  some  operative 
procedures;  that  is,  one  may  adopt  as  a  guide  the  Hippocratic 
axiom.  Quod  medicina  non  sanat,  ferrum  sanat:  What  medicine 
cures  not,  the  blade  cures. 

The  treatment  advised  by  C'elsus  is  first  to  attempt  to  destroy 
the  goitrous  tunic  by  escharoties  ;  and  when  the  tumor  is  thus 
opened,  the  content  will  flow  out  if  it  be  thin;  but  if  it  be  thick, 
it  should  be  pulled  out  with  the  fingers;  and  then  the  ulcer  which 
remains  is  to  be  healed  by  proper  dressings.  But  Celsus  says  a 
cure  with  the  scalpel  is  speedier;  and  for  this,  the  tumor  is  to  be 
incised  in  the  median  line,  and  the  tunic  exposed;  then  with  the 
finger  the  cyst  is  to  be  separated  from  the  .sound  structures,  and 
removed,  with  its  contents.  The  wound  is  now  to  be  cleaned  with 
vinegar  to  which  salt  or  nitre  has  been  added;  and  its  lips  are 
next  to  be  closed  by  means  of  sutures,  and  dressed  in  the  manner 
pursued  in  other  wounds. 

This  description  of  the  Celsian  treatment  shows  that  the 
Koman  surgeon  managed  the  goitre  intelligently  and  dextrously; 
and  one  finds  in  it  the  elements  of  the  operative  treatment  of  the 
present  time. 

Goitre  has  been  treated  operatively  by  the  following  proced- 
ures: the  seton,  simple  incision,  inci-sion  and  suture  maintaining 
the  wound  open,  strangulation  by  circumscribing  ligature, ligation 
of  vessels,  and  enucleation. 


GOITRE.  839 

The  treatment  by  seton  originated  with  Reid  and  0.  Beirne, 
and  should  be  limited  to  the  cystic  species;  it  has  been  recom- 
mended by  Nagel  and  Hamburger.  The  plan  of  Hamburger  was 
to  so  introduce  a  tube  that  it  would  afford  drainage  at  the  most 
dependent  portion  of  the  tumor;  the  lower  opening  was  made 
larger  than  the  tube.  The  seton  caused  much  reaction.  Adel- 
mann  advises  the  seton  in  the  goitrous  cyst  of  thin  walls.  The 
author  treated  a  case  by  the  use  of  the  seton  in  1869;  this 
was  a  large  cystic  goitre,  and  the  treatment  reached  through  a 
period  of  many  months.  Though  a  cure  was  thus  obtained,  the 
writer  would  not  adopt  this  plan  again. 

The  method  of  treatment  by  incision  is  suited  only  for  the 
cystic  species,  and  in  this  way  Adelmann  cured  some  cases.  In 
1867  Patruban  treated  by  incising  the  goitrous  cyst  freely;  and 
then  having  uplifted  the  bottom,  this  was  transfixed  with 
threads,  and  these  were  then  fastened  to  the  neck  outside,  so  that 
the  cavity  was  nearly  obliterated.  Xo  serious  reaction  followed, 
and  a  cure  in  six  weeks  was  obtained.  After  making  a  free 
incision,  and  the  content  having  been  evacuated,  the  inner  wall 
of  the  cyst  may  be  brushed  with  a  strong  solution  of  iodine;  and 
then  the  cavity  may  be  filled  with  iodoform  gauze,  and  redressed 
as  required. 

The  method  by  strangulating  ligature  is  adapted  to  the  solid 
species  of  goitre.  It  was  used  by  E.  S.  Cooper,  of  San  Francisco, 
in  a  case  observed  by  the  writer.  As  the  operation  was  done  in 
the  suppurative  age  of  surgery,  the  unsatisfactorv  result  which 
followed  the  work,  was  not  a  fair  test  of  this  plan  of  treatment. 
It  is  probable  that  subcutaneous  circumscription  of  the  vascular 
or  glandular  form  of  goitre,  done  aseptically,  would  effect  a  cure. 

Goitre  has  been  treated  by  ligation  of  the  nutrient  arteries; 
this  has  been  chiefly  done  in  the  vascular  species.  In  1829  Langen- 
beck  tied  the  superior  thyroid  artery  on  the  right  side;  and  in 
another  case  he  tied  the  common  carotid  artery.  Soon  afterwards 
Chelius  performed  ligation  of  the  superior  thyroid  arteries  in 
four  cases,  with  success.  And  in  1852,  Porta  tied  the  superior 
and  inferior  thyroid  arteries  for  the  cure  of  goitre.  Tins  plan  of 
treatment  has  been  pursued  by  but  few  surgeons.  When  it  is 
done,  it  would  serve  a  better  purpose  were  it  the  preliminary  act 
in  the  work  of  enucleation. 

A  more  satisfactory  treatment  is  to  remove  the  growth  at.  once 
by  the  plan  known  as  enucleation.  AVolfier,  in  his  monograph 
on  the   surgical   treatment  of  goitre,  says  that  in  1771,   A^ogel 


840  TIIVKUID    GLAND    AND    ITS    AFFECTIONS. 

partially  excised  the  goitrous  tumor  after  having  tied  the  vessels. 
In  1791  Desault  removed  one-hall"  of  the  diseased  thyroid  gland. 
The  gland  was  first  systematically  removed  \>y  Iledenus,  in  1800; 
he  separated  the  muscles  from  the  gland,  and  tied  all  the  vessels. 
In  1817  Von  Walter  tied  the  superior  thyroid  arteries  with  the 
intention  of  inducing  atro])hy  of  the  gland.  Galen  noticed  that 
the  recurrent  nerve  might  be  im})aired  in  the  removal  of  the 
gland.  Zang,  in  modern  times,  observed  that  loss  of  the  voice 
might  result  from  removal  of  the  thyroid  gland.  Jobert,  in 
1843,  advised  electro-puncture;  and  later,  extirpation  was  done 
by  the  galvano-caustic  process. 

Ill  1842,  Sedillot  published  an  account  of  the  extirpation  of  a 
large  goitre;  his  incision  was  made  along  the  border  of  the 
sterno-cleido-mastoid  muscle;  twenty  vessels  were  tied,  some  of 
which  were  as  large  as  the  little  finger. 

Dieffenbach,  for  the  cure  of  goitrous  tumor,  advises  to  extir- 
pate the  glandular  siiecies;  to  treat  the  vascular  by  ligation,  and 
the  cystic  form  by  the  seton. 

Woerner,  who  wrote  in  1853,  would  treat  the  cystic  form  by 
incision,  butthe solid  species  by  extirpation.  Extirpation,  which 
he  pronounces  a  perilous  operation,  is  to  be  done  by  a  long  incis- 
ion, in  which  the  tumor  is  laid  bare  and  dissected  out  with  the 
fingers,  the  handle  of  the  scalpel,  closed  scissors  and  forceps. 
When  large  vessels  are  brought  into  view,  then  a  pair  of  curved 
scissors  should  be  carried  under  them,  and  along  this  an  aneu- 
rismal  needle,  carrying  two  threads,  so  that  the  vessel  can  be  tied 
at  two  points,  and  then  divided  between  the  ligatures.  Large 
veins  which  swell  up  during  the  dissection, should  be  tied,  and  then 
severed.  Thus,  step  by  step,  the  operation  is  so  done  that  the 
surgeon  works  almost  in  non-bleeding  tissue.  If  large  processes 
pa.ss  underneath  the  sternum,  Woerner  divides  them  with  the 
ecraseur.  One  of  the  risks  attending  this  extirpation  was  sec- 
ondary bleeding;  and  from  this  some  patients  were  lost. 

In  1872,  Warren  Greene,  an  American  surgeon,  reported  cases 
of  extirpation  of  goitre,  done  as  follows:  lay  bare  the  tumor  by  a 
straight  incision,  in  which  the  capsule  must  not  be  opened. 
When  the  tumor  is  thus  well  displayed,  its  capsule  is  to  be  opened 
and  the  contents  enucleated  and  removed  with  the  fingers  and 
handle  of  the  scalpel;  and  he  advises  to  do  this  rapidly  and 
regardless  of  the  hgemorrhage;  the  aim  of  the  operator  being  to 
reach  the  thyroid  arteries  as  soon  as  possible,  and  to  tie  them. 
When  the  inferior  attachment  or  pedicle  is  reached,  it  is  to  be 


GOITRE.  841 

transfixed  with  a  blunt  needle  and  each  half  securely  tied,  and  sec- 
tion then  made  above  the  ligature. 

Kocher,  in  1S74,  wrote  on  the  treatment  of  goitre;  his  method 
was  similar  to  that  of  Luecke;  he  treated  the  hyperplastic  form 
by  injections  of  tincture  of  iodine.  This  injection,  in  the 
cystic  form  with  thick  walls,  will  not  cure;  indeed,  such  injection 
only  thickens  the  walls.  The  cystic  species  is  better  suited  for 
treatment  by  incision.  But  in  the  gelatinous,  vascular,  hsemor- 
rhagic  and  soft  follicular  species,  as  well  as  in  the  fibrous  form, 
the  best  treatment  is  enucleation  of  the  tumor.  The  proper 
method  of  doing  this  is  to  divide  the  skin  over  the  growth,  open 
the  fibrous  capsule,  and  tie  all  the  vessels  which  are  met.  Next 
proceed  with  the  enucleation,  and  when  large  vessels  are  found 
in  the  peduncular  part  of  the  growth,  they  are  to  be  ligated. 
Where  the  growth  is  firmly  attached  to  the  trachea,  the  mass 
must  be  included  in  a  ligature,  severed,  and  the  remaining  stump 
cauterized  with  carbolic  acid.  The  edges  of  the  remaining  cap- 
sule are  to  be  drawn  outwards,  and  sutured  to  the  skin.  In  cases 
of  gelatinous  material,  Kocher  opens  the  growth  and  clears  out 
the  content  with  his  fingers,  and  temporarily  fills  the  cavity  with 
sponge ;  after  the  bleeding  is  thus  arrested,  he  fills  the  cavity  with 
carbolized  lint,  wdiich  is  changed  from  time  to  time. 

In  1879,  Wolfler  reported  on  the  extirpation  of  goitre  as  pur- 
sued in  the  surgical  clinic  of  Billroth.  Instead  of  a  T  or  V- 
incision,  the  tumor  was  laid  bare  by  a  vertical  cut  which  was 
median  in  position,  or  along  the  border  of  the  sterno-cleido- 
mastoid  muscle.  The  capsule  was  opened  on  a  grooved  director, 
and  to  control  bleeding,  the  forceps  of  P^an  was  used.  The 
recurrent  nerve  must  be  carefully  guarded,  as  there  is  danger  of 
injuring  it.  In  eighteen  months  he  operated  fifteen  times;  and 
only  in  one  case  was  it  necessary  to  perform  tracheotomy.  The 
removal  was  done  under  the  thymol  spray.  In  four  of  the  cases, 
the  recurrent  nerve  w^as  partially  palsied,  yet,  afterwards,  its 
function  returned.  Garre,  of  Basel,  describes  and  commends  the 
method  pursued  by  Socin  in  the  removal  of  goitre ;  he  laid  bare 
the  capsule  of  the  growth,  and  then  removed  the  component 
nodules  with  his  fingers  (the  plan  of  Celsus).  The  hsemorrhage 
was  not  great,  and  was  controlled  by  clasp  forceps. 

Between  the  years  1877  and  1896  the  author  has  performed 

enucleation  in  eighteen  cases  of  goitre;  many  years  prior  to  this, 

in  1858,  the,  writer,  when  a  junior  member  of  the  surgical  corps  of 

the  United  States  Navy,  removed  a  goitre  of  moderate  dimensions 

54 


842  THYROID    GLAND    AND    ITS   AFFECTIONS. 

from  a  woiiian  iii  Chinandega,  a  city  of  Nicaragua.  Of  tlie  eigiit- 
een,  fifteen  recovered,  and  three  died.  One  death  was  from  second- 
ary bleeding;  this  patient,  a  mulatto,  was  neglected  by  the  nurse 
and  allowed  *to  bleed  nearly  to  death  before  the  medical  attend- 
ant, who  had  been  intrusted  with  the  case,  was  notified.  Another 
died  from  collapse  of  the  trachea  after  the  tumor  had  been 
removed  and  the  wound  closed.  After  the  wound  had  been 
closed,  syncope  ensued,  which  was  thought  due  to  the  large 
amount  of  blood  that  was  lost  during  the  operation.  Artificial 
respiration  by  Silvester's  mode  was  resorted  to;  also  inversion  of 
the  body  and  bandaging  the  limbs  to  force  the  blood  to  the 
brain ;  and,  as  last  resort,  the  wound  was  reopened,  when  the 
trachea  was  found  so  collapsed  that  it  was  probable  that  in  the 
movements  of  artificial  respiration,  but  little  air  had  entered  the 
lungs.  Though  the  trachea  was  opened,  and  a  tube  inserted  and 
air  blown  in,  yet  the  patient  did  not  rally.  Death  in  this  patient 
was  clearly  due  to  the  collapse  of  the  trachea,  of  which  the  walls 
had  lost  their  powers  of  resistance  through  the  continued  pressure 
of  the  tumor.  In  the  third  fatal  case,  there  arose,  soon  after  the 
operation  was  completed,  a  tumultuous  action  of  the  heart,  the 
pulse  beating  over  one  hundred  and  forty  times  a  minute.  This 
inordinate  cardiac  action  continued  until  death,  which  occurred 
on  the  fifth  day  after  the  operation.  The  heart,  being  exhausted 
from  over-action,  ceased  to  beat.  An  explanation,  which  may  be 
offered  of  the  disturbance  of  the  heart  in  this  case,  is  that,  in  the 
enucleation,  the  cardiac  branches  of  the  sympathetic  nerve  were 
wounded  ;  those  nerves,  which  regulate  or  inhibit  excessive  action, 
were  deprived  of  their  controlling  influence.  During  the  five 
days  which  this  patient  lived,  the  wound  healed  rapidly;  in  fact, 
there  was  almost  comf)lete  closure  without  suppuration. 

The  operation  as  done  by  the  author  consists  in  making  an 
incision  by  which  the  tumor  is  brought  into  view;  and  such 
incision  should  be  made  vertically  in  the  median  line  of  the 
derm  covering  the  goitre.  The  first  operation  done  by  the  writer 
was  performed  prior  to  the  era  of  "antiseptic  surgery,'"  and  before 
the  introduction  of  the  haemostatic  forceps,  which  has  given  the 
surgeon  such  perfect  and  speedy  control  of  bleeding.  This  oper- 
ation was  performed  on  a  woman  in  Chinandega,  Nicaragua,  in 
1859;  and  as  aids  were  a  German  and  an  American  physician, 
residents  of  that  city.  As  it  Was  thought  possible  that  the  woman 
might  die  during  the  operation,  the  priestly  official  with  his 
tapers  and  other  appanage  in  use  there  in  the  death  ceremonial, 


GOITRE.  843 

stood  near  by  to  perform  the  last  offices,  should  the  knife  render 
them  necessary.  Tiie  patio  of  the  Spanish  house,  and  the  street 
in'  front,  were  crowded  with  curious  spectators  of  tlie  bloody 
drama  which  was  to  be  enacted :  a  scene  in  which  the  operator  and 
patient  played  parts  as  interesting  to  that  motley  company  of 
witnesses,  as  did  the  gladiators  of  old  to  the  Roman  corona,  which 
once  filled  the  Coliseum.  The  operation  was  a  very  bloody  one, 
and  midway  in  the  work,  the  bleeding  was  so  profuse  that  one 
of  the  assistants  was  seized  with  panic,  and  begged  that  the  work 
should  cease  there.  These  remonstrances  were  not  heeded;  the 
patient  could  not  have  run  more  .risk  from  concluding  the  work 
than  from  leaving  the  half-enucleated  tumor  in  her  neck.  By  the 
careful  ligation  of  vessels,  and  dissection  of  the  growth  from  the 
parts  to  which  it  was  attached,  the  work  of  removal  was  brought 
to  a  fortunate  issue.  The  patient  soon  recovered,  and  was  amply 
repaid  for  the  risk  of  submitting  to  an  operation  which  had 
rarely  been  done  :  risks  here  augmented  through  submitting  to  a 
knife  which  had  been  disciplined  by  but  little  experience. 

In  subsequent  operations  done  by  the  writer,  after  the  skin 
was  divided,  the  muscles  which  lie  on  the  goitre  were  uplifted 


Figure  93.     Representino;  the  transfixor  used  by  the  writer  in  the  enuclea- 
tion of  goitre. 

and  turned  aside,  and  held  ^o  by  large  blunt  retractors;  thus  the 
capsule  was  divided,  and  if  the  growth  were  cystic  or  cystoid  in 
structure,  it  was  enucleated,  and  the  vessels  which  entered  it 
were  doubly  tied  and  divided  between  the  ligatures.  If  the 
tumor  be  of  the  vascular  or  glandular  species,  then  the  work  is 
much  more  difficult  than  if  the  development  is  cystic;  a  great 
number  of  ligatures  must  be  tied ;  every  artery  and  vein  must  be 
carefully  secured.  And  to  accomplish  this  safely,  the  writer 
practices  a  method  that  may  be  named  interstitial  transfixion. 
For  this  purpose  he  uses  an  instrument  which  from  its  use  may 
be  called  a  transfixor.  This  instrument,  as  seen  from  the  drawing, 
is  an  extremely  curved  forceps,  of  which  the  points  are  somewhat 
blunt,  yet  are  sharp  enough  to  permit  of  the  instrument  being 


844  THYROID    (JLANK    AND    ITS    AFFECTIONS. 

thrust  through  the  structure  underneath  vessels.  "When  the 
traiisiixor  is  thrust  through  a  section  of  the  tumor,  the  points 
are  opened,  and  two  ligatures  are  caught  and  drawn  through. 
The  material  used  for  ligature  was  silken  thread  which  hud  been 
carbolizedor  saturated  with  alcohol.  The  two  threads  were  tied, 
leaving  an  interval  between  tliem,  wdiich  was  divided  with  blunt 
scissors.  Thus  proceeding,  section  by  section  containing  vessels 
may  be  tied  and  severed.  In  his  recent  operations  the  writer 
has  used  catgut  ligatures. 

If  large  vessels  be  met,  these  should  be  isolated  from  the 
neighboring  tissues  as  much  as  .possible,  and  ligated.  The  writer 
has  not  seen  that  large  development  of  the  arteries  which  some 
surgeons  report  to  have  met  in  this  operation.  The  veins,  in 
number  and  calibre,  exceed  the  arteries;  and  these  vessels  are 
also  to  be  tied  doubly,  and  severed  between  the  ligatures.  Thus 
done,  there  will  be  lost  but  little  blood,  and  the  danger  of  intra- 
venous aspiration  is  avoided. 

"When  the  tumor  is  of  the  glandular  species  and  the  isthmus 
with  one  or  both  lobes  is  enlarged,  then  the  growth  is  closely 
adherent  to  the  trachea,  and  separation  of  the  two  demands  cau- 
tious dissection,  lest  the  windpipe  be  opened.  Also,  the  traction 
made  on  the  trachea  lessens  its  calibre;  enough,  in  fact,  to  asphyx- 
iate the  patient,  unless  the  surgeon  occasionally  suspends  the 
work  until' the  cyanosis  is  relieved  by  free  respiration.  In  cases 
in  which  the  growth  penetrates  into  the  niche  between  the 
trachea  and  the  oesophagus,  then  in  the  removal  of  the  tumor, 
the  recurrent  laryngeal  nerve  will  be  imperiled;  especially  so,  if 
the  growth  is  seated  on  the  left  side.  "With  due  care,  the  nerve 
can  be  spared;  and  though  partial  or  complete  aphonia  may 
follow  the  operation,  yet,  as  a  rule,  this  will  finally  disap])ear. 
If,  however,  the  nerve  on  both  sides  be  severed,  the  voice  will  be 
permanently  lost;  if  the  division  be  only  on  one  side,  then  the 
voice  will  be  reduced  to  a  species  of  falsetto  which  will  remain 
permanent.  And  as  these  aphonic  accidents  cannot  always  be 
foreseen,  the  surgeon  should  apprise  his  patient  of  the  possibility 
that  the  voice  may  be  injured  or  lost  by  the  operation.  In  no 
patient  operated  on  by  the  waiter  has  aphonia  been  produced; 
yet  in  the  majority  of  patients  there  has  been  some  temporary 
change  in  tone  of  the  voice. 

Jankowski,  in  1885,  wrote  on  the  aphonia  which  sometimes 
follows  the  removal  of  goitre;  he  finds  in  six  hundred  and 
twenty  operations  that  aphonic  conditions  occurred  eighty-seven 


GOITRE.  845 

times;  that  is,  in  fourteen  per  cent  of  the  cases.  Richelot,  wlm 
wrote  on  this  subject,  says  such  aphonia  might  arise  from  pres- 
sure of  the  tumor  prior  to  the  operation;  or  it  can  arise  from 
lesion  of  the  nerve  during  the  extirpation ;  and  finally,  from  sub- 
sequent cicatricial  contraction,  the  nerve  may  be  compressed,  and 
aphonia  thus  arise. 

For  a  few  days  following  the  operation,  the  patient  experiences 
great  difficulty  in  swallowing  food.  He  should  be  fed  on  liquid 
diet,  which  should  be  introduced  in  small  quantities;  thus 
the  movement  of  the  parts  is  reduced  to  a  minimum,  in  degluti- 
tion. A  drainage  tube  should  be  inserted  and  retained  in  the 
wound  for  a  few  days;  and  an  alcoholized  dressing  should  be 
applied  on  the  wound.  During  the  treatment,  to  permit  the 
escape  of  the  excreta,  the  patient  slfould  lie  on  the  side,  much  of 
the  time. 

In  1883,  Kocher  reported  two  hundred  and  forty  extirj)ations 
of  non-malignant  goitre,  of  which  twenty-eight  died;  that  is 
eleven  and  six-tenths  per  cent. 

Rotter  of  Wiirzburg,  in  1885,  wrote  on  the  mortality  which 
follows  the  removal  of  goitre.  He  finds  that  of  fifty-four  cases 
operated  on  before  1850,  seventeen  died;  from  1850  to  1876,  of  one 
hundred  and  fifty-four  cases  operated  on,  thirty-one  died,  and  the 
result  in  five  cases  was  not  published.  And  since  the  era  of 
antiseptic  surgery  of  four  hundred  and  five  cases  collected  by 
Rotter,  fifty-two  died;  that  is,  with  the  improvement  in  the 
method  of  operating,  the  mortality  has  been  reduced  to  near  eight 
per  cent;  and  later  'statistics  give  a  still  lower  mortality;  so 
that  the  operation  has  acquired  an  abiding  place  in  surgery 
among  those  procedures  which  lessen  human  suffering  and  pro- 
long life. 

Recent  experience  has  revealed  the  fact  that  the  removal  of 
the  goitre  is  not  always  an  unalloyed  blessing  to  the  patient.  In 
1883  J.  L.  and  A.  Reverdin,  famous  for  the  introduction  of  skin- 
grafting,  observed  that  the  entire  removal  of  the  thyroid  gland 
was  followed  by  loss  of  appetite,  irregular  gait,  paleness  of  the 
skin  and  dementia;  that  is,  a  species  of  idiocy  was  induced;  and 
the  conditions  present  are  similar  to  a  disease  described  and 
named  by  Sir  William  Gull,  myxoedema.  The  Reverdins  claim 
that  the  loss  of  the  thyroid  gland  leads  to  a  deposit  of  mucin  in 
the  tissues,  and  causes  a  disturbance  in  the  central  system  of  the 
sympathetic  nerve.  They  advise  that  the  gland  should  not  be 
wholly  removed.     In  the  same  year  Kocher  announced  that  in 


846  THYROID    GLAXD    AND    ITS    AFFECTIONS. 

eighteen  cases  in  wliicli  the  gland  was  wholly  removed,  there 
were  two  in  whom  the  health  was  impaired;  while  in  sixteen 
there  was  a  disturbance  of  the  general  health,  and  a  degeneration 
of  the  patient's  physical  and  mental  powers.  The  limbs  were 
weak,  heavy  and  easily  tired,  and  there  was  transient  or  perma- 
nent oedema  of  the  skin.  Kocher  names  this  condition  cachexia 
strumipriva,  and  he  regards  it  as  akin  to  dementia  or  idiocy.  In 
1884  Crede'  reported  fourteen  cases  of  total  extirpation  of  the 
gland,  and  the  strumiprivous  cachexia  did  not  occur  in  any  of 
the  cases.  About  the  same  time,  Schiff  and  Zesas  experimented 
on  cats  and  dogs,  in  which  the  thyroid  gland  was  removed. 
SchifF  found  that  dogs  thus  treated  died  within  a  month.  Zesas 
thinks  the  gland  regulates  the  circulation  of  the  brain.  And  to 
compensate  the  loss  of  the»thyroid  gland  in  man,  it  has  been 
recommended  to  introduce  ])ortions  of  the  gland  derived  from  the 
sheep  into  the  structures  of  the  connective  tissue,  or  into  the 
abdominal  cavity. 

About  this  period,  a  new  disease  hitherto  unknown  was 
noticed,  described  and  named  myxcedema  :  a  morbid  state  in 
which  there  are  conditions  present  similar  to  some  which  exist  in 
cretinism,  and,  also,  are  very  analogous  to  those  which  follow 
total  removal  of  the  thyroid  body:  an  analogy,  in  fact,  so  close 
that  it  is  permitted  to  infer  that  cachexia  strumipriva  and 
myxcedema  are  cognate  or  identical,  and  should  be  amenable 
to  similar  treatment.  And  as  a  remedy,  the  fluid  extracted  from 
the  thyroid  gland  of  some  animal,  as  the  ox  or  sheep,  suggests 
itself  as  a  rational  remedy  to  be  used  by  the  mouth,  or  b}' 
interstitial  injection. 

In  1887  there  were  additional  contributions  to  the  literature 
of  this  subject  by  Bruns  and  Hoffa,  who  claim  that  the  entire 
thyroid  body  cannot  be  removed  with  impunity:  the  cachexia 
strumij)riva  will  certainly  supervene;  and  that  when  such 
cachexia  has  not  followed  thyroid  extirpation,  it  was  because  the 
gland  had  not  been  entirely  removed,  or  that  a  portion  of  it  had 
been  reproduced.  Again,  the  absence  of  cachexia  strumipriva 
can  be  explained  by  the  coexistence  of  an  accessory  thyroid  gland ; 
the  exi.stence  of  such  supernumerary  thyroid  lias  been  verified 
by  the  researches  of  Gruber,  Streckei.sen,  Zuckerkandl  and  Made- 
lung,  who  have  found  that  such  an  anomaly  is  not  infrequent. 

Bruns  advises  to  remove  but  one-half  of  a  bilateral  goitre: 
thus  proceeding  the  cachexy  will  always  be  avoided.  Bruns 
announces  that  he   has  operated  on  forty-eight  cases  of  goitre. 


EXOPHTHALMIC    GOITRE.  847 

leaving  a  portion  of  the  gland  in  each ;  and  in  no  case  did  the 
cachexy  appear. 

In  his  recent  thyroidectomies  the  writer  has  pursued  the  plan 
here  suggested;  where  the  entire  thyroid  body  was  goitrous,  a 
fragmentary  portion  of  it  was  left,  with  favorable  result.  In  one 
case,  the  fragment  which  was  left  enlarged  so  as  to  cause  some 
trouble;  yet  this  enlargement  was  arrested  and  caused  to  recede 
by  the  hypodermic  injection  of  the  tincture  of  iodine;  and 
hy  the  occasional  use  of  such  injection  during  a  period  of  four 
months,  the  patient  was  permanently  relieved. 

Many  reports  have  been  made  of  total  extirpation  of  the 
thyroid  gland,  and  yet  no  ill  consequence  resulted  to  the  patient; 
and  in  some  of  the  writer's  first  work,  prior  to  his  knowledge  of 
cachexia  strumipriva  and  its  associate  myxoedema,  he  believed 
that  he  extirpated  the  part  totally  and  still  no  trouble  followed. 
It  is  possible,  however,  that  here  the  removal  was  not  complete, 
and  that  some  fragmentary  portion,  fortunately  for  the  subject, 
was  left  behind. 

In  conclusion,  then,  a  rule  in  the  performance  of  thyroidectomy 
should  be,  to  leave  behind  a  portion  of  tlie  gland ;  and  this 
should  be  the  least  affected  part  of  the  gland;  and  its  site,  if 
Ijossible,  should  be  lateral  and  not  median;  and  should  this 
remaining  part  become  the  seat  of  goitrous  degeneration,  it 
should  be  treated  by  the  hypodermic  injections  of  iodine,  as  has 
been  described. 

Exophthalmic  Goitre. — In  the  field  in  which  Surgery  and 
Internal  Medicine  have  possessory  rights,  the  actual  claims  of 
each  being  undetermined,  lies  a  disease  akin  to  goitre,  and  which 
from  one  of  its  symptomatic  features  is  named.  Exophthalmic 
Goitre.  And,  as  is  usual  in  the  cure  of  disease  which  has  been 
noticed  by  a  number  of  cotemporaneous  observers,  a  number  of 
other  names  have  been  applied  to  it;  and  among  these  are  the 
names  of  two  of  the  original  observers:  to  wit,  it  is  sometimes 
known  as  Grave's  disease;  also  Basedow's  disease.  Another  name 
less  objectionable  than  the  latter  two,  may  be  constructed  from 
its  leading  symptoms,  viz.,  goitrous  ophthalmic  tachycardia. 

Basedow  was  more  fortunate  than  other  students  of  the  dis- 
ease in  observing  that  three  afiections  are  here  united  in  one, 
viz.,  of  the  eye,  thyroid  body  and  the  heart. 

The  symptoms  of  the  disease  are  as  follows:  the  subject, 
usually  a  female,  is  generally  chlorotic,  anaemic  and  hysterical; 
she  complains  of  cardiac  palpitation,  throbbing  in  the  prsecordial 


848  THYROID    GLAND    AND    ITS    AFFECTIONS. 

region,  and  an  upheaval  of  tlie  chest-wall  in  front  of  and  below 
the  region  of  the  heart;  the  cervical  vessels  beat  and  swell;  and 
finally  the  thyroid  gland  becomes  enlarged,  and  is  the  seat  of  a 
fremitus  and  blowing  impulse  and  sound.  Respiration  is  dis- 
turbed, and  cough  is  easily  excited.  Along  with  these  phenomena 
the  eye  becomes  more  prominent,  and  the  exposure  of  an  unusual 
amount  of  the  surface  of  the  sclerotica  gives  the  eye  a  striking 
appearance.  This  ocular  prominence  is  referred  by  Fano  to 
abnormal  development  of  the  vessels  of  the  orbits;  especially  of 
the  veins.  The  adipose  structure  "within  the  orbit  is  also 
developed  beyond  its  usual  dimensions;  and  this  contributes  to 
ocular  prominence.  And  Neumann  has  observed  that  tlie  globe 
itself  is  sometimes  enlarged.     Visual  acuity  is  seldom  impaired. 

The  sympathetic  nerve  in  its  cervical  portion  has  frequently 
been  found  in  an  abnormal  condition.  And  this  may,  the  writer 
would  suggest,  act  on  those  longitudinal  muscular  fibers  in  the 
lid,  discovered  by  Miiller,  which  have  the  function  of  dilating  the 
palpebral  slit.  Rudolf  Wagner  verified  such  action  by  applying 
electricity  to  the  divided  nerve  in  the  neck  of  a  criminal  whose 
head  liad  just  been  decapitated. 

Of  the  trio  of  symptomatic  phtenomena  which  are  present, 
much  attention  has  been  given  to  the  enlargement  of  the  thyroid 
body.  Tliis  hypertrophy  never  reaches  the  voluminous  dimen- 
sions which  are  often  seen  in  cases  of  common  goitre.  The  devel- 
opment is  usually  uniform  and  bilateral;  though  exceptionall}^ 
it  is  limited  to  one  side.  The  changes  in  the  gland  are  limited 
chiefly  to  the  vascular  constituent,  and  the  anatomical  condition 
is  similar  to  that  of  erectile  tissue.  The  dilated  arteries  have 
numerous  intercommunications;  and  their  walls  are  often  the 
site  of  atheromatous  change.  The  veins  are  also  altered ;  they 
may  be  obliterated  into  fibrous  cords;  or  they  may  be  dilated, 
and  present  varicose  pouches.  The  proper  glandular  tissue  may 
be  unchanged;  yet  it  is,  sometimes,  somewhat  h3'pertrophied. 

Alterations  have  also  been  noted  in  the  heart;  the  organ  is 
hypertrophied;  the  ventricles  are  passively  dilated,  and  there  is 
valvular  imperfection,  fatty  degeneration  of  the  cardiac  tissue, 
and  atheromatous  changes  in  the  aorta. 

Females  are  predisposed  to  the  disease;  the  writer  has  not 
seen  it  in  the  male.  Withuisen,  who  has  collected  fifty  cases 
of  exophthalmic  goitre,  found  that  of  these  only  eight  were  in 
men.  The  affection  occurs  oftenest  between  the  ages  of  twent}' 
and  forty  years;  yet  Stokes  and  Fischer  have  each  seen  a  patient 
much  older. 


MALIGNANT    DISEASE.  849 

The  symptoms  which  have  been  enumerated  indicate  tlie 
nature  of  the  affection  with  sufficient  definiteness  to  enable  the 
surgeon  not  to  confound  exophthalmic  goitre  with  ordinary  goi- 
tre; a  matter  of  much  importance,  since  the  treatment  of  the 
former  is  medical  and  seldom  surgical.  Should,  however,  there 
be  doubt  as  to  the  true  nature  of  the  case,  it  is  better  for  a  time 
to  subject  the  patient  to  a  course  of  internal  medication.  The 
patient  must  be  placed  in  the  best  possible  hygienic  conditions. 
There  should  be  a  change  of  residence  from  inland  to  the  sea- 
side or  the  reverse,  according  as  the  patient  belongs  to  one  or  the 
other  location.  Hydrotherapy  is  specially  praised  in  the  man- 
agement of  such  cases.  Ice-cold  compresses  over  the  region  of 
the  heart  are  commended. 

As  internal  remedies,  iron  and  arsenic  may  be  used;  also 
digitalis.  Iodine,  so  valuable  in  ordinary  goitre,  usually  fails  to 
bring  relief  in  the  exophthalmic  form. 

If,  in  spite  of  the  means  here  indicated,  the  patient  should 
become  the  subject  of  a  large  goitrous  development,  then  it  would 
be  proper  to  attack  the  growth  by  some  of  the  means  described 
in  the  previous  chapter. 

Maligyiant  Disease  of  the  TJtyroid  Gland. — Malignant  disease  of 
the  sarcomatous  and  carcinomatous  form  appears  in  the  thyroid 
gland.     Sarcoma  is  said  to  occur  here  more  often  than  carcinoma. 

The  writer  has  seen  but  one  case,  which  was  that  of  carcinoma, 
which  appeared  in  the  thyroid  gland  of  a  man  who  was  fift}^ 
years  of  age.  When  first  seen,  the  growth,  somewhat  globular  in 
outline,  occupied  the  entire  site  of  the  gland,  and  was  somewhat 
more  than  three  inches  in  diameter.  It  was  closely  adherent  to 
the  air-passages,  and  of  dense  structure,  unyielding  to  pressure. 
The  overlying  skin  was  slightly  puckered  or  plicated,  and  so 
inseparably  adherent  to  the  growth  that  it  seemed  to  be  a  part  of 
the  latter.  The  tumor  had  become  slightly  painful,  and  from  its 
connections  with  the  trachea  and  oesophagus,  it  interfered  some- 
what with  breathing  and  swallowing. 

An  attempt  was  made  to  remove  this  growth,  yet  the  task  was 
a  difficult  one;  and  the  adhesions  to  the  trachea  were  such  that 
it  was  impossible  to  thoroughly  remove  the  growth  without  open- 
ing the  windpipe;  and  since  this  would  have  left  an  unhealing 
breach  there,  it  was  deemed  prudent  to  leave  the  tracheal  canal 
intact,  which  was  accomplished  by  removing  the  tumor  in  cunei- 
form sections.  The  cancerous  tissue  was  similar  to  the  cicatrized 
scirrhus  occurring  in  the  mammary  gland.  It  was  non-vascular, 
so  that  tlie  work  was  done  with  but  little  loss  of  blood. 


850  THYROID    GLAND    AND  ITS    AFFECTIONS. 

The  result  of  the  operation  was  some  temporary  relief  to  the 
patient;  the  latter,  however,  survived  hut  a  few  months;  and 
would  probahly  have  lived  as  long  if  the  tumor  had  not  been 
interfered  with. 

From  the  experience  in  tliis  case,  should  a  similar  one  present 
itself,  instead  of  extirjiation,  tlie  writer  would  make  trial  of  the 
l)arenchymatous  injection  of  an  arsenical  solution,  viz.,  Fowler's 
solution,  of  which  there  should  first  be  injected  five  drops;  and 
should  this  not  cause  much  irritation,  the  dose  injected  may 
gradually  be  increased  in  amount.  Thus  beginning  with  a  few 
drops,  the  author  has  found  that  by  slowly  increasing  the  quan- 
tity, finally  the  patient  will  tolerate,  without  dangerous  reaction, 
thirty  drops  of  Fowler's  solution,  injected  at  different  points  in 
the  malignant  growth.  The  tolerance  of  so  large  a  dose  is  proba- 
l)ly  due  to  imperfect  development  of  the  absorbents  in  the  neo- 
plasm. 

Wounds  of  the  Thyroid  Gland. — Traumatic  lesions  of  the  gland 
named  in  the  order  of  their  frequency  are  the  contused,  incised, 
and  penetrating.  The  gravity  of  such  wound  is  less  in  the  sound 
gland  than  in  that  which  is  goitrous. 

The  contused  wound  may  accompany  an  attempt  at  strangu- 
lation done  by  the  patient  himself;  or  it  may  be  inflicted  by  the 
hands  of  others.  The  prominent  symptom  is  the  ecchymosis  of 
blood  due  to  rupture  of  the  thyroid  vessels;  and  tliis  maybe 
slight  or  so  extensive  as  to  permeate  the  tissues  from  the  chin  to 
the  sternum.  The  overlying  skin  is  livid  or  i)urple,  and  there  is 
tumefaction  proportionate  to  the  effused  blood.  Difficulty  of 
breathing  and  swallowing  may  be  present,  due  to  pressure. 

If  such  contused  wound  is  limited  to  the  thyroid  gland,  recov- 
ery may  be  ex})ected;  but  if  the  larynx  or  trachea  be  fractured  or 
torn,  then  life  is  imperiled;  in  the  former  case,  the  treatment 
should  be  that  employed  in  a  simple  contusion,  local  means 
which  will  favor  absorption  of  the  effused  blood.  But  if  the  con- 
tusion be  associated  with  additional  injury  of  the  air-passage, 
then  the  patient's  chances  of  recovery  will  be  increased  by  an 
early  performance  of  tracheotom}',  in  which  the  canula  must  be 
inserted  below  the  injured  gland.  Should  su])puration  ensue, 
the  pus  should  be  given  escape  by  an  early  incision.  "Where 
the  contusion  has  destroyed  the  thyroid  structure,  so  that  the 
patient  is  similar  to  one  from  whom  the  gland  has  been  removed, 
then  symptoms  of  cachexia  strumipriva  may  occur,  as  happened 
in  a  case  seen  by  Guerlon-Dudon;  the  gland  here  had  been 
destroyed  by  the  passage  of  a  wlieel  over  tlie  neck. 


THYROIDITIS.  851 

The  incised  wound  is  generally  from  an  attempt  at  suicide,  in 
which  the  wound  is  made  with  a  razor,  or  other  knife-like  instru- 
ment; or  such  w^ound  may  be  made  by  the  surgeon  in  the  opera- 
tion of  tracheotomy.  In  such  wound,  the  first  duty  of  the  surgeon 
is  to  arrest  and  control  the  bleeding;  and  means  to  do  this  are 
ligation  of  the  vessels  in  the  open  wound,  or  by  transfixion;  and 
should  the  rapid  escape  of  blood  not  permit  this,  then  plugging 
the  wound  with  the  first  material  at  hand,  should  be  resorted  to. 
Styptics,  so  often  used,  are  not  trustworthy,  since  through  the 
destruction  of  tissue  which  they  cause,  secondaiy  haemorrhage 
can  ensue.  Transfixion  and  inclusion  of  masses  of  the  vascular 
structure  in  ligatures  would  be  one  of  the  safest  and  speediest 
ways  of  controlling  the  bleeding. 

In  the  performance  of  tracheotomy,  bleeding  is  avoided  by 
careful  dissection,  and  likewise,  by  seizing  and  twisting  the  vessels 
which  may  accidentally  be  opened.  The  proposal  to  seek  for  the 
thyroid  arteries  and  ligate  them  in  such  cases,  is  ill  advice;  for  it 
is  probable  that  before  the  operator  had  fully  displayed  the 
quadrangle  containing  the  four  vessels,  his  patient  would  scarcely 
require  further  attention. 

The  penetrating  wound  is  rare  in  the  normal  gland;  but  as  a 
means  of  treatment  in  the  goitrous  gland  it  is  frequent;  and  as  a 
rule,  such  wound  is  harmless;  yet  exceptionally,  it  has  proved 
fatal.  Liicke,  Demme,  Schmidt  and  Schwalbe  have  seen  death 
soon  result  from  suff'ocation,  after  injections  into  the  goitrous 
gland.  Severe,  and  even  fatal  bleeding  has  resulted  from  such 
slight  penetrating  wound.  Suppuration  thus  arising  has  caused 
the  patient's  death. 

TJiyroiditis. — Inflammation  of  the  thyroid  gland  maybe  acute 
or  chronic;  the  acute  form  is  that  in  which  surgical  aid  is  often- 
est  sought. 

It  occurs  somewhat  oftener  in  females;  and  a  goitrous  condition 
predisposes  to  such  inflammation.  It  is  announced  by  a  chill, 
and  a  rise  in  pulse  and  temperature.  There  are  pain  and  a  sense 
of  oppressive  tension  about  the  neck.  The  tumefaction  maybe 
unilateral,  or  on  both  sides.  The  writer  saw  a  case  in  which  the 
swelling  was  uniform,  both  on  the  sides  and  on  the  front  of  the 
neck. 

There  may  be  headache,  ringing  in  the  ears,  and  in  the  sever- 
est cases,  delirium.  The  tumor  obeys  the  movements  of  the 
larynx,  rising  and  falling  in  deglutition ;  yet  it  may  be  so  extensive 
as  to  prevent  such  movement;  and  then,  according  to  Gosselin, 


852  THYKOID    GLAND    AND    ITS    AFFECTIONS. 

such  immobilization  of  the  air-passage  disappears  in  the  same 
ratio  as  the  agglutinative  tumefaction  vanishes. 

By  palpation,  the  hard  and  tense  structure  of  the  swollen 
gland  can  be  traced  out;  and  if  lateral,  the  tumor  will  be  felt 
above,  passing  under  the  sterno-cleido-mastoid  muscle;  while 
below,  it  may  dip  underneath-  the  clavicle  and  sternum,  and, 
also,  be  felt  on  the  outside  of  the  sterno-cleido-mastoid  muscle. 

Such  tumor,  from  pressure  on  the  windpipe,  may  obstruct 
breathing;  it  may  also  obstruct  swelling;  and,  from  pressure  on 
the  recurrent  nerve,  coughing  and  hoarseness  may  arise.  And 
great  pressure  on  the  vagus  nerve  has  caused  sudden  death. 

Thyroiditis  may  terminate  by  resolution,  induration,  suppu- 
ration or  gangrene;  and,  as  stated,  speedy  death  may  arise 
through  pressure  causing  suffocation. 

In  the  cases  which  disappear  by  resolution,  the  swelling 
appearing  on  the  second  day,  increases  till  the  fourth  or  fifth  day, 
or  even  later  in  severe  cases;  then  it  remains  stationary  for  a 
variable  time,  and  finally  disappears  at  the  end  of  two  or  three 
weeks.  This  normal,  or  desirable  course,  may  be  varied  by 
accessions,  remissions,  cessations  and  other  variations,  which  are 
determined  by  the  morbid  elements  present  in  the  case.  The 
rapidity  of  disappearance  is  dependent  on  the  condition  of  the 
venous  and  absorbent  routes  through  which  the  redundant 
elements  composing  the  structure  may  find  escape.  Such  resolu- 
tion may  be  incomplete,  and  then  the  gland  remains  enlarged, 
and  the  condition  becomes  one  of  indurated  goitre. 

In  cases (jf  more  intense  action,  the  event  may  be  suppuration; 
here  chills,  increase  of  volume,  pain  and  other  functional  disturb- 
ance are  present.  There  is  cedennitous  tumefaction  of  the  integ- 
ument; and  this  may  reach  from  the  chin  to  the  sternum,  and 
even  extend  down  on  the  chest-wall.  Fluctuation  is  slow  to 
appear,  and  the  usual  evidences  of  pus  are  absent.  The  tume- 
fied structures  are  dense,  tense  and  unyielding  to  pressure;  and 
if  the  forming  pus  is  deep-seated,  it  may  remain  undiscovered  for 
a  time,  and  in  the  interim,  the  pus  may  migrate  laterally,  or 
penetrate  dee})er.  In  the  graver  cases,  the  imprisoned  pus  may 
erode  the  subjacent  tracheal  or  laryngeal  cartilages;  or  penetrat- 
ing the  interstices  between  these  structures,  it  may  enter  the 
windpipe.  In  a  patient  seen  by  the  writer,  in  which  the  inflam- 
mation extended  beyond  its  ])rimary  site,  the  deep-seated  pus 
penetrated  the  larynx,  and  finally  destroj-ed  the  woman's  life. 

The  pus  has  perforated  the  oesophagus;  and  this  has  occurred 


PHLEGMON    AND    ABSCESS.  853 

during  the  act  of  vomiting,  in  which  the  thin  intervening  wall 
was  ruptured. 

By  gravitation  the  pus  has  descended  to,  and  entered  the 
pleural  cavity;  and  such  event  is  a  most  unfavorable  one,  since,  in 
the  cases  reported,  death  through  exhaustion  generally  occurred. 

Gangrene,  resulting  from  suppurative  thyroiditis,  has  not 
unfrequently  been  observed.  In  the  case  cited  by  the  author, 
there  was  gangrene  of  the  overlying  derm;  and  this  destructive 
process  implicated  the  subcutaneous  fatty  tissue.  In  seven  cases 
of  this  kind  collected  by  Lebert,  there  were  four  recoveries. 

From  an  attempt  to  calculate  the  mortality  of  thyroiditis, 
Lebert  finds  eleven  deaths  in  thirty-two  cases;  that  is,  one-third 
of  the  cases  died.  These  figures  of  fatality  are  manifestly  too 
high.  The  complication  of  goitre  in  the  patient  adds  much  to 
the  gravity  of  the  disease;  and  where  this  is  absent,  thyroiditis 
may  be  considered  nearly  free  from  danger. 

In  the  treatment  of  the  disease,  an  attempt  should  be  made  to 
remove  the  congestion  of  the  affected  structure ;  and  this  may  be 
directly  affected  by  the  application  of  leeches  to  the  part.  Or 
this  may  be  done  by  scarification,  in  which  slight  penetrating 
wounds  are  made  into  the  swollen  gland;  and  though  there 
might  be  risk  of  wounding  arteries,  yet  the  bleeding  that  thence 
might  arise  could  be  controlled  by  temporary  pressure.  After 
this,  the  inflamed  surface  should  be  painted  frequently  with 
tincture  of  iodine.  The  free  circulation  of  blood  through  the  neck 
must  be  promoted  by  proper  position.  As  a  resolvent,  mercurial 
ointment  ma}^  be  applied  in  the  later  stage  of  the  inflammation. 

Should  the  means  mentioned  not  arrest  the  inflammation,  and 
there  be  indications  of  the  formation  of  pus,  there  should  be  no 
delay  in  making  one  or  more  incisions  to  give  the  pus  exit- 
Such  incision  is  at  the  risk  of  opening  a  vein  or  artery;  this  risk, 
however,  is  slight,  if  one  determines  beforehand  the  presence  of 
pus  by  a  small  hollow  needle.  The  purulent  material  should  be 
washed  out,  and  its  site  well  irrigated  with  some  antiseptic  fluid. 
The  treatment  may  then  end  by  the  application  of  poultices  or 
antiseptic  compresses. 

Phlegmon  and  Abscess  of  the  Neck. — Phlegmonous  inflammation 
of  the  neck  may  be  rapid  or  acute  in  course;  or  it  may  be  chronic; 
and  it  may  be  generally  diffused;  or  the  action  may  be  limited 
to  a  small  part  of  the  surface  of  the  neck.  When  circumscribed, 
the  aff'ection  may  be  limited  by  the  anatomical  components  of 
the  neck ;  and  then  it  may  lie  above,  or  below  the  hyoid  bone;  in 


854  THYROID    GLAND    AND    ITS    AFFECTIONS. 

fact,  it  may  be  situated  at  any  point  on  the  front  surface  of  the 
neck;  or  the  bauk  of  the  neck  may  be  the  isohited  site  of  the 
phlegnjDD.  This  classihcation  of  site  is  that  of  Gillette,  who 
refers  the  inflammation  to  local  and  general  causes. 

As  local  causes  are  those  of  a  traumatic  character;  and  these 
comprise  the  various  lesions  of  the  neck  which  may  arise  from 
some  external  agency;  even  wounds  made  by  the  surgeon  him- 
self have  awakened  a  widespread  phlegmon  on  the  neck.  Lesion 
of  the  mucous  membrane  of  the  oral  and  buccal  cavity  has, 
through  the  lymphatic  channels,  awakened  iufiammation  in  the 
neighboring  glands  of  the  neck;  and  the  latter  have  transmitted 
the  same  to  the  adjacent  connective  tissue.  Eruptions  of  the 
skin  of  the  face  or  neck  may  light  up  a  morbid  action  of  the  cer- 
vical glands,  and  thence  suppuration  may  arise.  Disease  in  the 
pharynx  and  larynx  has  extended  from  its  })riniary  site,  and 
appeared  in  the  cervical  glands. 

The  fracture  of  the  low^er  jaw,  in  cases  in  which  the  gingival 
structure  is  opened,  may  cause  abscess  in  the  supra-hoidean 
region;  and  such  pus  may  descend  much  lower  on  the  neck. 
Calculus  in  the  submaxillary  gland,  or  in  its  ducts,  may  develop 
cervical  phlegmon  or  abscess. 

Adenoid  disease  dependent  on  syphilis  or  scrofula  ending  in 
suppuration  of  the  glands  and  peri-giandular  tissue,  is  a  frequent 
cause  of  abscess;  and  this  usually  runs  a  tedious  course.  Cell- 
multiplication  due  to  the  dyscrasic  vice  is  the  initial  phenome- 
non; and  the  superabundant  cells  at  that  stage  probably  act  as 
mechanical  irritants.  And  other  diseases,  as  the  eruptive  ones 
of  the  skin,  in  which  the  organism  is  laden  with  effete  detritus, 
besides  awakening  abscess  elsewhere,  has  a  special  tendency  to 
cause  suppuration  in  the  cervical  structures. 

The  terms  phlegmon  and  abscess,  though  representing  morbid 
conditions  closely  cognate,  differ  in  this  respect,  that  phlegmon 
is  a  suppurative  process  in  which  unlimited  diffusion  is  the 
characteristic  feature ;  while  in  abscess,  the  action  is  isolated,  and 
within  palpable  and  visible  bounds.  Phlegmon  has  the  accom- 
paniment of  severe  constitutional  disturbance,  viz.,  general  fever, 
and  sometimes  delirium  ;  while  abscess  is  limited  to  local  pain, 
swelling  and  suppuration.  Phlegmon  produces  great  destruction 
of  the  ti-ssues;  in  fact,  it  may  terminate  life  through  gangrene 
and  general  pyiiimic  destruction. 

The  phlegmonous  or  diffused  suppuration  may  be  superficial, 
or  outside  of  the  superficial  cervical  fascia:  viz.,  external  to  that 


PHLEGMON    AND    ABSCESS.  S55 

fascia  which  extends  from  the  hyoid  bone  to  the  front  of  the 
sternal  manubrium  and  clavicle;  and  which  laterally  includes 
the  sterno-cleido-mastoid  muscles  and  the  trapezei.  Or  the  pus 
may  form  between  the  superficial  and  middle  fascise;  or  it  may 
be  between  the  middle  and  inmost  fascial  structure.  The  power 
of  these  fasciiB  to  limit  and  prevent  the  passa<^e  of  pus  through 
them  is  overrated;  these  fasciae  are  too  thin  in  texture  to  exercise 
such  imprisoning  force  in  cases  in  which  there  is  a  large  purulent 
collection. 

Thesupra-hyoid  structures,  and  those  in  the  floor  of  the  mouth, 
from  their  proximity  to  the  site  of  infecting  lesions,  are  the  fre- 
quent site  of  suppurative  inflammation;  and  such  pus  may  per- 
forate the  skin  and  appear  externally;  but  occasionally,  it  appears 
beneath  the  tongue,  within  the  mouth;  and  in  this  site,  the  pos- 
sibility of  a  sialolith  being  the  causal  agency,  should  not  be  for- 
gotten. The  supra-hyoidean  collection  of  pus  may  point  also 
towards  the  pharynx,  the  larynx  or  oesophagus;  and  in  any  of 
these  events,  there  may  be  disturbance  of  the  voice,  breathing  or 
swallowing. 

The  wisdom  tooth  has  been  the  cause  of  such  abscess;  and  this 
has  appeared  at  the  angle  of  the  lower  jaw. 

Vidal  and  Duplay  have  seen  cases  of  abscess  which  arose  in 
the  structures  at  the  base  of  the  epiglottis.  Such  cases  are  accom- 
panied by  oedematous  swelling  within  the  pharynx,  and  all  the 
functional  disturbances  which  arise  from  swelling  there;  and  of 
these,  by  far  the  most  important  is  the  swollen  condition  of  the 
aryteno-epiglottidean  folds  of  mucous  membrane,  which  may  be 
so  great  as  to  fatally  narrow  the  air-passage. 

An  occasional  site  of  such  inflammation  and  suppuration,  as 
pointed  out  by  Velpeau,  is  within  the  sheath  of  the  sterno-cleido- 
mastoid  muscle;  the  muscle  becomes  painful  and  contracted,  and 
as  result,  the  head  is  deviated  to  that  side.  But  more  frequently, 
this  suppurative  action  is  connected  with  the  chain  of  glands 
which  lie  along  the  vessels  and  close  to  the  muscle.  The  swell- 
ing, owing  to  the  implication  of  the  cervical  plexus,  is  attended 
with  much  pain;  and  as  just  said,  there  is  torticollis  from  con- 
traction of  the  sterno-cleido-mastoid.  The  morbid  action  is  of 
phlegmonous  character  in  its  manifestations;  and  the  pus  fre- 
quently travels  downwards,  or  in  some  other  direction  away  from 
its  primary  point  of  origin;  sometimes,  penetrating  the-  thorax. 
A  form  of  suppuration  of  the  neck  of  a  widely  diffused  character, 
was  observed  and  described  by  Dupuytren.     This  abscess  may 


856  THYROID    GLAND    AND    ITS    AFFKCTIONS. 

appear  in  j)i'oportious  so  great  that  it  occupies  the  entirety  of  the 
region,  from  the  mastoid  process  to  the  clavicle,  and  reach  later- 
ally to  the  trapezius  muscle.  The  dominant  feature  is  tumefac- 
tion, which  is  so  great  as  to  obscure,  or  blot  out,  the  normal 
prominences  of  the  neck.  And  the  }»us  which  forms  can  gravi- 
tate into  the  thorax,  or  appear  on  its  outer  wall.  Dupuytren 
observed  this  affection  among  public  criers  and  auctioneers. 

The  writer  has  seen  two  cases  of  that  wide-opened  cervical 
phlegmon,  wiiich  was  due  to  an  adynamic  form  of  erysipelas: 
both  speedily  ended  in  death.  In  the  cases  described  by  Dupuy- 
tren, the  course  was  a  slow  one;  and  in  the  pus  which  infiltrated 
the  structures  subcutaneously,  there  was  generated  gas,  which 
yielded  crepitation  on  pressure. 

These  severe  forms  of  cervical  suppuration  are  often  connected 
with  some  anginous  disease  in  the  pharynx;  a  septic  trouble 
there  located  is  transmitted  through  the  lymjihatic  vessels  to  the 
cervical  glands;  the  first  morbid  phenomena  being  lymphangitis 
and  adenitis. 

Phlegmonous  inflammation  may  occur  on  the  posterior  side 
of  the  neck;  yet  the  anatomical  structures  of  the  neck  behind 
are  less  adapted  to  such  morbid  development  than  those  of  the 
anterior  side;  the  paucity  of  loose  connective  tissue,  the  close 
adherence  of  the  muscles,  and  the  small  number  of  the  cervical 
glands,  are  conditions  unfavorable  to  phlegmonous  diffusion. 
The  posterior  cervical  phlegmon  is  exceedingly  painful;  due  to 
tiie  thick,  un3delding  character  of  the  overlying  skin;  and  also 
to  the  tendon-like  density  of  the  muscles  composing  the  nuclea. 

The  diffused  phlegmonous  abscess  situated  in  the  anterior 
cervical  region,  often  requires  special  attention  on  the  part  of  the 
surgeon  to  rescue  the  patient  from  the  disastrous  events  or  com- 
plications which  may  arise  in  the  course  of  such  disease,  viz.,  the 
irruption  of  the  })us  into  the  tliorax,  the  trachea,  or  (jeso})hagus; 
and  a  3'et  more  formidable  event  is  the  erosion  and  0})ening  of 
tlie  carotid  artery  or  the  internal  jugular  vein.  The  opening  of 
tiie  air-passage  may  necessitate  the  performance  of  tracheotomy; 
and  the  perforation  of  a  blood-vessel  would  demand  immediate 
tamponing;  and  the  subsequent  ligation  of  the  vessel.  In  a 
l^tient  seen  by  the  writer  in  which  the  suppuration  was  of  glan- 
dular origin,  the  suppurative  action  had  so  weakened  the  wall 
of  the  internal  jugular  that  when  an  opening  was  made  into  the 
purulent  collection,  the  internal  jugular  spontaneously  burst  into 
the  cavity,  and  for  a  moment  bled  in  a  frightful  manner.     This 


PHLEGMON    AND    ABSCESS.  857 

was  controlled  by  a  plug  of  sponge,  and  some  days  afterwards, 
when  this  was  removed,  no  more  bleeding  occurred;  yet  it  is 
probable  that  if  aid  had  not  been  at  hand,  death  would  have 
occurred  within  a  few  minutes. 

The  unsparing  pen  of  the  surgical  historian  has  not  failed  to 
keep  in  remembrance  an  error  committed  by  Listen,  in  which 
this  famous  surgeon  inadvertently  mistook  an  aneurism  on  the 
neck  for  an  abscess,  and,  against  the  warning  of  his  clinical 
assistant,  he  thrust  a  bistoury  into  the  tumor  and  caused  a  bleed- 
ing which  ended  fatally.  The  memory  of  this  act,  as  he  con- 
fessed to  a  friend,  remained  as  an  enduring  sorrow  in  his  heart. 
This  case  fully  illustrates  the  need  of  deliberate  thought  accom- 
panying, as  a  guiding  mentor,  all  surgical  work.  Unthinking 
routine  erelong  stumbles  upon  danger. 

Dolbeau  was  compelled  to  tie  the  external  carotid  on  account 
of  ulcerative  erosion  of  the  lingual  artery.  As  a  rule,  however, 
according  to  the  observations  of  Gross,  Duplay  and  others,  such 
ulcerative  erosion  occurs  oftener  in  the  large  vessels  of  the  neck 
than  in  the  small  ones. 

The  pus,  while  the  overlying  skin  is  yet  intact,  may  perforate 
the  air-passage,  and  then  be  expelled  by  coughing;  and  also, 
gravitating  to  the  lungs,  it  may  produce  ichorous  pneumonia. 

As  already  mentioned,  the  pus  from  the  cervical  phlegmon 
may,  if  deep  seated,  pass  down  the  plane  of  the  prsevertebral 
muscles  and,  entering  the  pleural  cavity,  it  may  develop  pleuritis 
and  empyema ;  such  complication  is  very  perilous;  usually,  after 
long  continuance,  ending  life  by  exhaustion. 

Deep-seated  abscess  of  the  chronic  type  may  have  its  origin 
in  vertebral  disease;  and  such  suppuration  may  be  near  the 
pharynx  and  discharge  into  the  pharyngeal  cavity,  but  if  the 
disease  be  lower  down,  then  the  pus  might  open  into  the  air- 
passage,  or  into  the  oesophagus,  or  it  might  gravitate  into  the 
thorax,  and  appear  in  the  mediastinal  space,  or  penetrate  the 
pleural  cavity:  any  of  which  events  would  be  very  perilous  to  the 
patient.  The  most  fortunate  event  would  be  that  the  purulent 
material  should  form  an  opening  posteriorly,  since  such  a  route 
of  escape  would  be  the  least  injurious  to  the  structures. 

Dumesthe,  who  wrote  on  cervical  abscess  in  1864,  observed 
that  the  anatomical  conditions  of  the  neck  are  such  that  the 
superficial  abscess  will  open  externally,  while  the  deep-seated 
tends  to  gravitate.  As  means  of  diagnosis  of  the  deep-seated 
species  he  directs  to  press  the  finger  down  on  the  anterior  edge  of 
55 


858  THYROID    GLAND    AND    ITS    AFFECTIONS. 

the  sterno-cleido-mastoid  while  those  of  the  other  hand  are  forced 
down  close  to  the  outer  margin;  now  between  the  fingers  thus 
insinuated,  the  fluctuation  of  deep-seated  pus  may  be  detected. 
Deep-seated  abscess  contiguous  to  a  vein  may  receive  and  trans- 
mit a  venous  murmur.  But  the  most  important  act  in  diagnosis 
is  the  distinction  of  a  collection  of  pus  from  an  aneurisnial  tumor, 
where  the  former  is  the  seat  of  a  movement  and  vibratile  impulse 
similar  to  what  occurs  in  an  aneurism.  If  studied,  there  is  a  dif- 
ference in  the  movements  of  the  two:  the  purulent  collection  is 
lifted  directly  upwards  by  the  subjacent  pulsating  artery;  buttlie 
aneurismal  tumor  expands  in  all  directions;  the  abscess  can  some- 
times be  displaced  from  the  vessel,  and  then  the  impulse  will 
vanish.  And,  as  a  crucial  test,  where  palpation  cannot  solve 
doubt,  the  hypodermic  needle  of  fine  calibre  may  be  used;  if  the 
tumor  be  aneurismal,  arterial  blood  w^ill  escape  through  the 
needle;  but  if  there  be  pus,  a  drop  of  this  may  be  drawn  out. 
Such  exploratory  acupuncture  is  harmless,  whatever  the  content 
may  be. 

Treatment. — The  cervical  phlegmon  and  abscess  have  been 
treated  by  different  methods;  collected  in  general  groups,  these 
are  antiphlogistic,  resolvent  and  operative. 

As  antiphlogistic  means  are  bleeding,  general  and  local,  and 
vesication.  General  bleeding  would  rarely  be  appropriate;  only 
in  the  plethoric  subject  should  it  be  resorted  to.  Depletion  may 
be  done  locally  by  leaching  and  scarification;  preferably  by 
scarification.  To  scarify,  one  should  use  a  sharp-pointed  lance 
or  bistoury,  and  a  number  of  vertical  stabs,  reaching  through  the 
skin  slightly  into  the  subcutaneous  tissue,  should  be  made;  and 
to  promote  bleeding  from  these  wounds,  the  surface  should  be 
bathed  with  water  rendered  alkaline  with  carbonate  of  soda  or 
potassa,  or  with  aqua  calcis.  An  antiphlogistic  measure  which 
has  had  numerous  advocates  is  vesicatio  volans,  or  the  flying 
blister,  as  it  is  popularly  stvled.  The  action  of  the  cantharidal 
vesicant  for  such  purpose  was  pointed  out  by  Dr.  Physic,  many 
years  ago:  Physic  claimed  that  impending  gangrene  could  thus 
be  prevented.  Velpeau  and  Quinart  have  recommended  vesica- 
tion in  the  cervical  phlegmon.  Quinart  applies  a  blister  which 
covers  the  site  of  the  abscess,  and  extends  some  distance  beyond 
its  border.  After  the  epiderm  is  thus  detached,  he  dresses  the 
surface  with  mercurial  ointment.  And  when  the  surface  heals, 
he  reapplies  the  vesicant;  and  thus  proceeding,  Quinart  claims 
that  the  course  of  such  abscess  may  be  greatly  shortened. 


PHLEGMON    AND    ABSCESS.  859 

As  resolvent  local  applications,  lint  saturated  with  an  alkaline 
solution,  or  with  simple  warm  water,  acts  well.  Or  LinimentQin 
Calcis,  used  in  the  same  way,  is  an  excellent  application.  As  an 
unguent,  mercurial  ointment,  or  stramonium  ointment  diluted  to 
one-fourth  the  officinal  strength,  may  be  used.  And,  finally, 
despite  the  censure  and  obloquy  that  have  been  cast  on  the  poul- 
tice by  fastidious  criticism,  it  yet  lives.  The  charge  that  it  is 
dirty  is  due  rather  to  the  compounder  than  the  compound  itself; 
it  assuages  pain  and  brings  ease  and  comfort  to  the  inflamed  part, 
and  from  the  alleviation  which  it  once  brought  to  the  writer,  the 
linseed  cataplasm  has  an  abiding  place  in  affectionate  memory; 
so  kindly,  indeed,  that  he  fully  concurs  with  the  agreeable  eulogy, 
which  the  surgeon  Gibson  has  joaid  the  poultice.  And  along 
with  the  cataplasm,  some  resolvent  ointment  may  be  used.  And 
these  means  are  often  advantageously  employed  along  with  the 
surgical  methods,  which  will  now  be  considered. 

Of  operative  means  by  which  the  cervical  phlegmon  or  abscess 
may  be  attacked,  the  simplest  is  that  of  tapping,  which  is  done 
with  a  hollow  needle  or  trocar  of  small  calibre:  a  method  which 
was  inaugurated  by  Voillemier  and  highly  commended  by  him; 
and  was  named  by  him  capillary  puncture,  or  tapping.  An 
analogous  plan  is  that  of  withdrawing  the  pus  with  an  aspirator; 
this  has  been  pursued  by  Lawson  Tait.  A'^oillemier  resorted  to  this 
plan  in  infants  three  or  four  years  old,  in  whom  abscess  arose 
from  inflamed  cervical  glands.  With  a  fine  trocar,  he  withdrew 
what  pus  would  easily  flow  out;  and  this  procedure  was  repeated 
on  the  second,  third  and  fourth  days,  until  no  more  material 
would  escape;  then  for  a  week,  some  resolvent  ointment  or  poul- 
tice was  used.  By  such  a  course,  the  abscess  was  quickly  cured,, 
and  scarcely  a  visible  trace  remained  of  the  work  done. 

Lawson  Tait  used  an  aspirator  with  a  small  needle,  and 
repeated  the  tapping  until  the  pus  ceased  to  reform.  In  aspi- 
rating, the  needle  must  not  traverse  the  same  point  twice.  The 
needle  must  be  inserted  obliquely;  and  this  should  be  done  from 
before  backwards;  yet  the  reverse  is  permissible;  and  as  to  the 
number  of  times,  Tait  fixes  no  limit;  in  one  case  he  aspirated 
fifty  consecutive  times,  and  obtained  a  cure. 

This  method  is  applicable  to  both  the  acute  and  chronic  forms; 
yet  in  the  chronic  abscess,  the  tapping  will  have  to  be  repeated 
more  times,  and  the  treatment  is  often  protracted. 

Two  points  of  much  importance  should  be  remembered  in  this 
plan  of  tapping  or  aspirating;  the  surface  operated  on  must  be 


800  THYROID    GLAND    AND    ITS    AFFECTIONS. 

well  cleansed  before  it  is  opened,  and  no  air  sliould  be  allowed 
to  enter  the  cavity;  especially,  in  tlie  chronic  form;  for  its 
adniis.'fion  greatly  aggravates  the  case.  The  advantage  claimed 
for  the  method  described  is  its  simplicity ;  and  especially,  the 
slight  scarring  which  arises  from  it;  an  important  thing  on  the 
surface  of  the  neck,  where  scars  remain  as  a  visible  deformity. 

A  second  plan  of  treatment  is  the  introduction  of  a  seton 
through  the  wall  of  the  j)us-cavity.  This  procedure  was  practiced 
and  commended  by  Darby;  also  by  Bonnafont.  Cotton  or  silken 
thread  was  used.  Wire  was  also  used  for  this  purpose.  Crean,  of 
Manchester,  reports  the  treatment  of  twenty-eight  cases  of  scrofu-' 
lous  or  critical  abscess,  as  he  names  it,  v.'hich  were  treated  by  the 
introduction  of  silver  wire  introduced  as  a  seton  through  the  wall 
of  the  abscess. 

Though  a  cure  may  be  obtained  by  the  seton,  yet,  as  St.  Ger- 
main counsels,  caution  should  be  exercised  in  its  use;  the  thread 
or  wire  should  not  be  permitted  to  remain  in  place  until  it  causes 
ulceration,  or  the  formation  of  granulative  tissue  at  the  entrance 
and  exit  points  of  the  thread.  As  soon  as  such  ulceration  begins 
the  seton  should  be  removed,  and  the  pus  permitted  to  flow 
through  the  opening  thus  made;  and  if  such  opening  is  insuffi- 
cient, then  the  seton  might  be  introduced  at  another  point. 

The  seton  is  obnoxious  to  two  grave  objections;  during  its  use, 
should  the  pus  harden  and  occlude  the  opening  around  the  cord 
or  wire,  then  an  erysipelatous  inflammation  may  be  excited  there, 
and  invading  the  contiguous  structures,  spread  thence  indefinitely. 
And  another  objection  is  that  the  seton  inevitably  leaves  a  scar 
which  time  will  not  efface.  Hence,  as  a  means  of  treatment,  the 
writer  would  discard  the  seton;  it  is  less  efficient  and  satisfactory 
than  the  following  method. 

Drainage. — The  drainage  tube  was  introduced  by  Chassaignac; 
and  though  assailed  by  countless  arrows  of  its  adversaries,  yet 
these  are  becoming  fewer;  it  has  nearly  outlived  opposition,  and 
gained  an  assured  place  in  the  list  of  surgical  weapons. 

The  use  of  the  drainage  tube  mu.st  be  preceded  by  one  or  more 
incisions  which  penetrate  to  the  pus;  and  these  openings  should 
be  made  in  the  long  axis  of  the  neck,  so  that  the  pus  can  follow 
the  natural  course  of  gravitation;  viz.,  from  above  downwards. 
The  drain  should  be  made  of  black  rubber  tubing;  it  must  be 
fenestrated,  or  have  lateral  openings  in  the  portion  which  is  to  lie 
in  the  cavity.  It  should  reach  to  the  bottom  of  the  cavity;  and, 
in  some  cases,  it  is  well  to  let  the  tube  traverse  the  cavitv  and 


PHLEGMON    AND    ABSCESS.  861 

reach  somewhat  beyond  the  outlet  and  inlet.  As  a  rule,  it  is 
better  to  have  one  or  more  tubes,  of  which  one  end  lies  buried 
in  the  cavity,  while  the  other  rises  somewhat  above  the  surface. 
As  the  cavity  closes,  the  tube  is  extruded  and  must  be  cut 
shorter,  from  time  to  time.  If  the  tube  is  placed  permanently 
in,  and  its  ends  tied  together,  then  it  should  daily  be  cleansed  by 
injecting  an  aseptic  fluid  through  it;  but  if  sections  of  tubing 
are  introduced  into  the  cavity,  these  should  daily  be  removed,, 
cleansed  and  replaced.  The  dressing  should  be  done  gently, 
lest  the  reparative  process  be  disturbed;  for  violent  injection 
may  tear  asunder  the  adhering  walls;  also,  displace  the  new- 
formed  cells,  and  open  vessels,  and  cause  bleeding.  But  if 
the  fluid  be  permitted  to  purl  through  the  pus  cavity  with- 
out pressure,  then  the  disturbances  mentioned  will  be  avoided, 
and  the  surgeon  will  second  the  work  of  restoration  to  struc- 
tural integrity.  The  drainage  tube  should  not  remain  too  long;; 
as  soon  as  the  material  discharged  changes  from  a  purulent 
to  a  serous  nature,  then  the  tube  is  no  longer  needed,  and  its 
longer  retention  in  the  wound  will  increase  the  scar,  which  must 
remain  afterwards.  In  fact,  the  chief  charge  against  the  drainage 
tube  is  that  it  is  an  irritant,  and  always  leaves  some  cicatricial 
vestiges  of  its  use. 

The  usual  and  most  important  operative  procedure  is  that  of 
incision  by  which  a  direct  outlet  is  formed  for  the  pus.  For  this 
purpose,  the  scalpel,  bistoury  or  other  instrument  in  the  use  of 
which  the  surgeon  has  acquired  facility,  may  be  employed. 
If  the  case  be  one  of  circumscribed  abscess,  then  a  single 
opening  will  suffice;  but  if  it  be  a  diffused  phlegmon,  then 
several  openings  should  be  made,  so  that  the  purulent  ma- 
terial may  have  ready  escape.  And  these  openings  should  be 
made  by  first  dividing  the  skin  and  superficial  fascia,  and  then 
boring  through  the  remaining  wall  with  a  blunt  dissector,  or  the 
finger;  thus  proceeding,  there  is  but  slight  risk  of  wounding 
vessels.  The  incisions  should  be  made  in  the  longitudinal  axis 
of  the  neck.  After  the  pus-space  has  been  freely  opened,  the 
purulent  material  should  be  well  rinsed  out  with  a  sublimated 
or  other  aseptic  fluid;  and  if  the  cavity  be  deep,  then  the  drain- 
age tube  should  be  inserted,  as  before  described,  and  detergent 
irrigation  practiced.  Lint,  moistened  with  sublimated  or  alco- 
holized water,  should  be  placed  over  the  affected  part,  and  daily 
changed. 

The  time  when  the  opening  should  be  made  is  a  matter  of 


862  TIIYKOID    GLAND    AND    ITS    AFFECTIOXS. 

controversy:  some  urge  early  opening;  others  advise  delay  until 
the  pus  has  reached  the  skin;  most  surgeons  adopt  the  former 
plan;  and  this  is  the  practice  of  the  writer,  who  opens  the  skin 
and  adipose  stratum  with  a  short-handled  scalpel,  and  then  con- 
tinues the  penetration  with  some  blunt  instrument.  If  the 
phlegmon  be  extensively  diffused,  then  two  or  more  openings 
should  be  made  and,  through  short  tubes  inserted  into  each,  irri- 
gation should  daily  be  done.  By  this  proceeding  at  an  early 
period,  the  destruction  of  the  connective  tissue  will  be  lessened; 
and  the  extravasating  wandering  of  the  ichorous  pus  will  be 
avoided,  or  greatly  curtailed. 

There  is  a  form  of  phlegmonous  disease  which  was  described, 
in  1845,  by  Metzler,  which,  differing  from  the  species  above 
described,  has  been  reserved  as  an  appendix  to  this  chapter. 

Metzler  finds  traces  of  its  history  in  the  works  of  Gregory, 
Frank  and  Ludwig;  and  he  thinks  it  may  be  regarded  as  an 
anomalous  form  of  typhus,  with  a  tendency  to  special  localiza- 
tion. Associated  with  general  symptonis  of  typhus,  there  is 
deposited  a  yellowish,  gray,  fat-like  matter  in  the  subcutaneous 
tissue  of  the  neck;  and  this  tumefaction  is  usually  unilateral,  and 
commonly  seated  near  the  parotid  gland,  or  lower  jaw;  it  is  not 
red  or  painful,  and  the  overlying  skin  is  movable.  In  about  ten 
days,  gangrene  commences,  with  an  increase  of  the  constitutional 
symptoms. 

This  affection  has  been  seen  both  in  the  acute  and  chronic 
forms;  in  the  former,  death  may  ensue  in  ten  or  twelve  days;  but 
in  the  chronic  form  this  may  occur  at  a  much  later  time.  Recov- 
ery may  occur  by  dispersion,  with  perhaps  a  few  points  of  gan- 
grene in  the  skin;  or  there  may  be  extensive  suppuration  and 
breaking  down  of  tissue,  and  still  recovery  may  take  place.  Fis- 
tulous openings  may  continue  for  a  long  period,  and  even  the  sub- 
jacent bone  be  affected.  In  some  cases,  there  may  be  a  recession 
of  the  tumor,  and  death  quickly  ensue;  more  often,  however,  the 
fatal  ending  is  due  to  an  exhaustive  suppuration;  or  a  large  ves- 
sel may  be  ojicned  by  erosion,  and  the  patient  then  quickly 
bleeds  to  death.  The  pressure  on  the  vessels  and  nerves  of  the 
neck  may  contribute  to  a  fatal  issue. 

The  necropsy  shows  that  the  adjacent  muscles  are  decom- 
posed, while  the  glands  show  but  slight  changes;  the  parotid  has 
been  found  but  slightly  affected,  though  it  is  in  the  midst  of  dis- 
organized structure. 

This  affection  occurs  oftener  in  the  young  than  in  the  aged. 
Death  occurred  in  one-half  of  those  attacked. 


PHLEGMON    AND    ABSCESS.  863 

Metzler  observed  a  similar  affection  of  the  subcutaneous  cellu- 
lar tissue  in  otlier  parts  of  tlie  body. 

The  treatment  used  in  the  disease  in  the  commencement  com- 
prised emetics,  mild  laxatives,  diaphoretics,  blistering  the  affected 
surface,  and  discutient  ointments.  In  some  cases  the  affected 
part  was  vesicated,  the  epiderm  thus  detached,  and,  as  dressing, 
lint  was  applied,  saturated  with  the  following  solution: — 

^.     Hydrarg.  Chloridi.  Corrosivi 9j 

Aquse ^i 

Misce. 
Apply  this  until  an  incrustation  is  formed,  and  then  use  moist 
dressing  over  the  surface.     Should  pus  form  in  spite  of  this  treat- 
ment, open  with  the  bistoury. 

The  writer  in  his  comment  on  this  form  of  cervical  abscess, 
thinks  its  causation  may  be  found  in  the  embolic  processes  which 
sometimes  attend  or  follow  typhus  or  typhoid  fever  of  adynamic 
form ;  and  of  which  a  usual  site  is  the  parotid  gland.  The 
obstructed  vessels  retard  the  current  of  blood,  or  wholly  suspend 
its  movement;  and  thence  the  tissues,  not  being  nourished,  the 
conditions  for  developing  phlegmon  or,  its  kinsman,  gangrene 
are  present.  The  writer  has  seen  a  few  cases  which  fell  within 
this  group,  and,  as  a  rule,  they  ended  fatally. 


CHAPTER  XXVII 


TUMORS    OF    THE    NECK. 


The  cervical  region,  especially  the  anterior  portion,  is  richly 
fertile  in  neoplastic  growths,  which,  here  as  elsewhere,  naturally 
separate  themselves  into  two  classes:  the  benign  and  the  malig- 
nant. 

The  benign  class  may  be  divided,  as  Konig  has  done,  into 
those  of  liquid  content,  viz.,  cysts,  and  those  of  solid  or  semi-solid 
content. 

Cystic  tumors  of  the  neck  are  thus  classified  by  Konig,  to 
whom  the  writer  is  indebted  for  much  of  the  material  which  fol- 
lows: (1)  Those  containing  air.  (2)  Those  of  serous  content.  (3) 
Those  containing  blood.  (4)  Echinococcus  cyst.  (5)  Those  cysts 
that  have  arisen  from  the  softening  or  liquefaction  of  solid  growths 

Cysts  containing  air  are  directly  connected  witli  the  air- 
passages,  as  the  larynx  or  tracliea;  and  they  arise  from  a  j)rotru- 
sion  of  a  portion  of  the  wall  of  one  of  these  passages.  One  of  the. 
most  common  is  that  whicli  arises  from  a  hernia-like  protrusion 
of  the  thyro-hyoidean  membrane,  due  to  dilatation  of  the  ventricle 
of  Morgagni,  which  is  contained  in  the  larynx.  Cysts  thus  aris- 
ing have  been  seen  here,  of  the  dimensions  of  a  small  walnut. 

An  air-cyst  may  arise  from  the  trachea;  and  this  tracheocele 
has  been  seen  in  front,  at  the  side,  or  on  the  posterior  wall  of  the 
trachea.  This  cyst  may  be  congenital,  and  be  due  to  imperfect 
closure  of  the  branchial  cleft;  or  it  may  arise  from  violent  expi- 
ratory effort,  as  severe  coughing,  or  vomiting. 

Such  air-cyst  has  a  mucous  wall  similar  to  that  of  the  trachea; 
and  besides  air,  mucous  material  is  also  contained  in  the  cyst. 
It  is  dilated  and  contracted  alternately  in  expiration  and  inspira- 
tion. Respiration  is  rarely  much  affected;  yet  the  voice  may  be 
weakened  by  such  cyst. 

Something  analogous  to  this  is  the  pneumocele,  which  has 
been  observed   in  the  subclavian  fossa,  above  the  clavicle,  and 
whicli  is  due  to  the  apex  of  the  lung  protruding  hernia-like. 
(864) 


TUMORS   OF   THE   NECK.  865 

The  tracheocele  and  pneumocele  demand  no  treatment;  and 
a  knowledge  of  them  is  chiefly  of  diagnostic  value:  viz.,  such 
air  tumor  should  not  be  mistaken  for  an  abscess,  liquid  cyst,  or 
other  tumor.  Only  in  the  case  of  the  tracheocele  causing  much 
trouble  should  an  attempt  be  made  to  extirpate  it;  yet  this  neces- 
sity will  seldom  occur;  the  rule  being  in  such  cases  to  limit 
treatment  to  simple  compression,  should  the  cyst  disturb  by  its 
volume. 

Cysts  of  liquid  content  are  sometimes  found  in  the  median 
line  of  the  neck  near  the  upper  border  of  the  thyroid  cartilage 
and  hyoid  bone.  Near  the  notch  or  incisura  in  the  upper  edge 
of  the  thyroid  cartilage,  is  often  found  a  bursal  space;  and  this  is 
not  near  the  skin,  as  anatomists  have  stated,  but  it  is  subfascia, 
and  close  to  the  cartilage.  Near  this  space,  which  may  be  named 
the  prse-thyroid  bursa,  there  is  found,  sometimes,  a  bursal  space 
just  below  the  hj^oid  bone  in  the  median  line  of  the  neck,  which 
may  be  named  the  thyro-hyoid  bursa;  and  a  third  bursa  occa-. 
sionally  exists  near  the  upper  border  of  the  hyoid  bone  close  to 
the  insertion  of  the  genio-hyoid  and  the  genio-hyo-glossi  muscles.^ 

The  blind  cul-de-sac,  known  as  the  foramen  csecum,  at  the 
base  of  tlie  tongue,  and  a  small  gland  which  lies  on  or  near 
the  middle  of  the  hyoid  bone,  and  likewise  abnormally  located 
portions  of  the  thyroid  gland,  may  give  rise  to  cystic  devel- 
opment. 

The  bursal  spaces  mentioned  are  normally  so  small  that  they 
are  unknown  to  the  possessor;  yet  from  any  cause  that  can 
excite  inflammation,  they  may  become  cystic  tumors  of  greater 
or  less  dimensions;  and  then  they  contain  a  viscid  fluid;  and 
should  they  be  highly  inflamed,  pus  may  form  in  tiiem. 

A  cyst  arising  from  the  prse-thyroid  bursa  presents  itself  as  a 
round  tumor  located  on  and  above  the  Pomum  Adami.  Inas- 
much as  it  is  often  small  and  painless,  if  it  be  of  small  size,  it  may 
escape  observation;  but  when  it  attains  a  large  volume  it  pro- 
trudes externally,  and  likewise  internally,  beneath  the  tongue. 
In  deglutition  it  follows  the  movements  of  the  larynx. 

A  cyst  from  enlargement  of  the  thyro-hyoid  bursa  or  of  the 
supra-hyoid  bursa,  is  of  frequent  occurrence;  and  its  nature 
would  be  indicated  by  the  attachment  of  the  cyst  to  the  hyoid  bone. 

These  cysts,  when  they  grow  upwards  and  encroach  on  the 
sublingual  space,  simulate  ranula;  and  such  cyst  is  not  inaptly 
named  a  pseudo-ranula.  In  the  chapters  devoted  to  ranula,  this 
matter  has  been  treated  of. 


860  TUMORS   OF   THE   NECK. 

Boclidalek  and  Zuckerkundl  have  observed  cases  of  cyst 
derived  from  occlusion  and  subsequent  dilatation  of  the  fora- 
men ciecum.  And  Zuckerkundl  has  seen  cysts  which  were 
derived  from  a  degeneration  of  the  small  gland  which  lies  near 
the  body  of  the  hyoid  bone. 

An  accurate  diagnosis  of  these  bursal  cysts  based  upon  struc- 
tural origin  is  difficult,  sometimes  impossible;  and  this  is  due  to 
the  structural  ground  of  origin  being  so  limited;  and  also  to  the 
fact  that  the  bursfe  whence  they  arise  are  ver}'  close  together; 
such  diagnosis,  however,  is  of  no  practical  advantage  to  the 
patient. 

From  irregularities  in  development  of  the  visceral  arches  and 
closure  of  the  intermediate  clefts  cysts  arise;  and  these,  in  situa- 
tion, may  be  on  the  side  of  the  neck  or  near  the  median  line; 
those  on  the  sides  arise  from  the  ill-closure  of  the  horizontal 
clefts  between  the  arches,  while  those  in  the  median  line  arise 
from  defective  closure  of  the  anterior  ends  of  the  arche.s.  The 
cysts  comprised  in  this  group  may  contain  dermoid,  atheromatous 
or  liquid  content. 

Dermoid  cysts  of  large  volume  have  been  observed  here;  the 
content  of  such  may  be  epithelial  detritus,  sebaceous  matter  and 
hair.  Or,  not  infrequently,  it  is  a  pure  atheromatous  tumor  of 
sebaceous  content  unmixed  with  other  material. 

The  cyst  of  liquid  content  may  originate  from  irregular 
closure  of  the  clefts  between  the  arches;  and  the  usual  sites  of 
such  cyst  correspond  to  that  of  the  second  and  third  branchial 
clefts.  And  the  content  may  be  clear,  serum-like ;  or  it  may  be 
viscid  and  gelatinous  in  character. 

Both  the  cysts  of  atheromatous  and  serous  content  are  remark- 
able for  the  firmness  and  density  of  their  containing  sacs;  and 
this  sac  is  closely  adherent  to  parts  around;  the  latter  character- 
istic is  one  which  the  surgeon  who  has  removed  them  has  well 
learned. 

An  anomalous  miniature  thyroid  gland  may  degenerate  and 
assume  a  character  similar  to  some  of  the  cystic  forms  that  have 
just  been  mentioned.  Likewise,  the  lymphatic  gland  may  undergo 
changes  in  which  it  assumes  a  cyst-like  form. 

The  cysts  which  have  been  considered,  whether  of  dermoid, 
atheromatous,  or  liquid  content,  may  be  })resent  at  birth;  or  the)' 
may  develop  after  birth.  They  can  remain  stationary  for  a  long 
time ;  and  then  they  may,  from  some  cause,  often  unknown,  be 
awakened  to  fresh  development.     They  are  commonly  located  in 


LYMPH-ANGIOMA.  8G7 

some  part  of  the  space  between  the  larynx  and  the  parotide  an 
space,  frequently  near  the  angle  of  the  jaw.  Yet  in  a  few 
cases  the  growth  was  located  on  the  lowermost  part  of  the 
neck.  Exceptionally,  such  cyst  has  been  found  located  within 
a  lipomatous  tumor  of  the  neck. 

These  cysts  may  run  a  long  course  without  giving  inconven- 
ience, sometimes  even  not  attracting  the  attention  of  the  pos- 
sessor; again  they  may  attain  such  dimensions,  that  through 
compression  on  muscles,  nerves  or  vessels  they  cause  trouble. 
The  cyst  may  open  externally;  and,  very  exceptionally,  it  has 
ruptured  into  the  pharynx,  as  was  seen  by  Savory. 

When  it  opens  externally  a  fistulous  orifice  may  remain  indef- 
initely long ;  and  inflammatory  action,  alternately  appearing 
and  disappearing,  may  seriously  interfere  with  the  health  and 
comfort  of  the  patient.  And  when  such  perforation  is  threat- 
ened, it  is  better  to  resort  to  some  plan  of  treatment  which  will 
avert  the  consequences  of  a  rupture  of  the  cyst. 

Treatment. — As  curative  methods  of  these  cysts  are  excision, 
injection,  and  subcutaneous  ruj)ture;  the  latter  two  are  only 
suited  to  cases  of  liquid  content,  as,  for  example,  the  bursal. 

In  extirpation  the  containing  wall  must  be  wholly  removed  ; 
a  fragment  left  behind  will  insure  a  recurrence  of  the  cyst;  a  fact 
which  the  writer  has  verified  by  observation;  and  he  regrets  to 
add,  also,  in  practice.  The  close  adherence  of  the  cyst's  walls  to 
parts  contiguous  renders  dissection  tedious  ;  and  the  field  of 
work  is  obscured  by  the  bleeding  which  results  from  opening 
small  vessels  which  enter  the  wall  of  the  sac.  The  liquid  species 
may  be  treated  with  injection  of  tincture  of  iodine. 

Lymph- Angioma. — A  recent  chapter  has  been  added  to  the  sur- 
gery of  the  neck,  detailing  a  cystic  tumor  which  has  its  origin  in 
the  lymph  vessels  of  the  neck.  Koster  and  Wegner  have  dis- 
covered the  lymphatic  origin  of  these  growths.  Both  the  lym- 
phatic vessels  and  the  lymphatic  glands  are  concerned  in  the 
origin  of  this  tumor,  which  is  correctly  named  by  Wegner,  a 
lymph-angioma.  It  is  chiefly  found  in  the  newborn  child,  yet 
it  has  developed  in  adults ;  and  it  may  occur  elsewhere  than  in 
the  neck. 

At  birth  the  lymphatic  cyst  may  be  well  developed;  or  it  may 
be  in  the  first  period  of  development.  In  the  foetus,  miscarried 
at  an  early  age,  such  tumor  and  other  deformity  have  been  seen. 

Such  growth  is  a  congeries  of  smaller  cysts";  and  in  volume 
these  may  vary  from  the  size  of  a  pea  to  that  of  an  apple.     The 


868  TUMORS   OF   THE   NECK. 

growth  may  be  on  the  back  of  the  neck,  and  divided  there  into 
two  parts  by  the  ligamentum  nucha3.  The  containing  wall 
may  be  thin  or  thick;  and  sometimes  thin  plates  of  bi)ne  or 
cartilage  are  found  in  it.  From  the  main  wall  polypoid  processes 
sometimes  project  into  the  cystic  cavity.  The  content  varies;  it 
may  be  a  translucent  serum,  or  it  may  be  discolored  with  pig- 
ment; and  in  some  cases  it  is  gelatinous  in  character. 

This  cystic  tumor  is  usually  multiple,  and  then  contains  a 
number  of  hollow  spaces,  in  chain  form,  necklace-like;  or  as  an 
irregular  conglomerate,  it  may  lie  in  the  spaces  of  the  cervical 
connective  tissue,  in  which  normally  lie  the  lymph  vessels. 
And  following  the  loose  connective  tissue  spaces  of  the  neck,  the 
growth  develops  laterally,  as  well  as  inwards;  the  muscles  and 
vessels  are  severally  forced  asunder;  and  sometimes  the  cj'st  is 
closely  attached  to  the  veins.  It  grows  in  the  direction  of  the 
least  resistance;  and  may  ascend  on  the  face,  and  penetrate  the 
floor  of  the  mouth;  and  below,  it  may  penetrate  the  thoracic 
cavity. 

Though  this  cystic  growth  attains  great  dimensions,  it  rarely 
injures  the  muscles  on  which  it  encroaches;  though  from  such 
pressure  the  salivary  glands  may  be  caused  to  atrophy. 

In  some  cases,  this  cystic  growth  remains  subcutaneous  in 
site,  and  then  uplifting  the  skin,  the  surface  of  the  latter  is  ren- 
dered nodulated,  or  uneven.  But  if  the  growth  commences  deep 
in  the  structures  of  the  neck,  it  may  remain  invisible  for  a  long 
period,  especially  if  the  panniculus  adiposus  be  thick.  The  over- 
lying skin  commonly  remains  unaffected  in  its  texture,  and  often 
it  remains  freely  movable  over  the  subjacent  tumor. 

The  functional  disturbance  which  can  arise  from  the  lymph- 
angioma depends  on  its  site;  if  ^it  lie  superficial,  although  of 
broad  extent,  it  causes  but  little  trouble;  but  if  it  lie  deeper,  it 
may  impede  the  return  of  venous  blood  from  the  head,  and  dis- 
turb breathing  and  deglutition;  such  functional  disturbance  is 
exceptional;  and  commonly,  the  infantile  subject  shows  no  symp- 
tom except  slow  emaciation.  And  then,  if  the  lymph-angioma 
lies  deep,  the  diagnosis  of  the  causal  agency  of  such  emaciation  is 
not  easy  to  determine;  but  in  cases  in  which  the  growth  is  pres- 
ent as  a  nodulated  development  on  the  neck,  then  the  cause  of 
failing  nutrition  is  evident.  It  might  be  mistaken  for  a  lipoma- 
tous  growth ;  yet  a  puncture  with  the  hj^podermic  needle  would 
banish  doubt,  since  the  cyst  would  yield  its  characteristic  content. 

The  prognosis  of  this  lymphoid  cyst  is  not  auspicious;  a  few 


ANGIOMA.  869 

cases  through  spontaneous  rupture  of  the  tumor  have  recovered; 
a  few  have  yielded  to  surgical  treatment;  but  the  greater  number 
of  infants  so  affected  have  perished  through  gradual  atrophy. 

As  treatment,  extirpation,  free  incisions  and  injection  have 
been  resorted  to;  extirpation  is  difficult  to  do,  and  attended  with 
risk  of  life,  owing  to  the  irregular  tumor  penetrating  deeply  into 
the  structures  of  the  neck;  so  that  such  operation  has  often  been 
suspended  before  completion.  Multiple  incision  has  been  found 
to  be  a  safer  plan;  such  incision  causes  inflammatory,  and  per- 
haps suppurative  action,  tending  to  obliteration  of  the  lymphoid 
cystic  spaces.  Cases  have  been  treated  by  injecting  into  the 
affected  parts  some  corrosive  fluid,  as  a  solution  of  chloride  of 
zinc  or  the  tincture  of  iodine;  this  work  must  be  done  carefully, 
else  swelling  may  be  provoked  which  will  cause  suffocation. 
The  introduction  of  a  seton  through  the  affected  structure  is  rec- 
ommended by  Smith,  who  has  cured  cases  in  this  way;  others, 
however,  strongl}^  condemn  it. 

Amidst  these  conflicting  opinions  of  the  surgical  authorities, 
the  practitioner,  who  may  have  a  case  to  treat,  is  left  in  wavering- 
uncertainty  whether  he  shall  commit  his  i:)atient  to  the  resources 
of  nature,  which  here  are  equivocal,  or  adopt  one  of  the  means 
mentioned,  of  which  the  event  is  equally  equivocal;  and  were  the 
writer  to  adopt  the  latter  course,  he  would  inject,  drop  by  drop, 
a  five  per  cent  solution  of  chloride  of  zinc. 

The  cystic  lymph-angioma,  as  stated,  has  rarely  been  seen 
except  in  the  infant;  a  few  cases,  however,  have  been  seen  in  the 
adult,  and  were  situated  near  the  sterno-cleido-mastoid  muscle, 
either  above  or  below.  In  some  of  the  cases,  the  tumor  was 
easily  extirpated. 

Angioma. — Every  grade  of  angioma,  from  the  superficial 
blood-mark  and  capillary  telangiectasis  to  the  massive  cavernous 
tumor,  has  been  observed  on  the  neck.  Of  such  growths,  the 
cavernous  tumor  of  venous  structure  is  not  unfrequent;  and  this 
tumor  is  often  distinguished  by  its  tendency  to  spread  over  a 
large  part  of  the  surface  of  the  neck;  and  though  its  favorite  site 
is  the  supra-clavicular  fossa,  yet  it  may  extend  beyond  the  limits 
of  the  neck,  and  then  appear  upon  the  thorax  below;  or  the 
growth  may  appear  above  on  the  cheek,  or  within  the  mouth. 

The  venous  angioma  may  be  congenital;  or  it  may  appear 
later  in  life;  and  it  may  remain  of  an  unchanging  volume;  or  it 
may  lessen  in  form;  or  from  some  cause,  patent  or  latent,  it  may 
be  excited  in  increase  of  growth.     Through  compression,  the  vol- 


870  TUMORS    OF    THE    NECK. 

ume  may  usually  be  reduced;  yet,  if  the  angioma  have  but 
.slight  commuuication  with  contiguous  vessels,  then  pressure 
scarcely  changes  its  form.  The  angiomatous  tumors  when  near 
the  surface  are  easily  recognized;  but  when  situated  deep,  they 
liave  resemblances  to  the  deep-seated  lymphangioma  or  lipoma; 
in  such  cases,  doubt  can  be  exchanged  for  certainty  by  the  use  of 
the  hypodermic  needle,  through  which  the  content,  if  liquid,  can 
be  obtained.  The  lipoma,  through  its  attachment  to  the  skin,  if 
displaced,  carries  the  skin  with  it,  and  maps  the  latter  off  into 
rounded  elevations  and  intervening  depressions. 

Treatment. — As  treatment,  numerous  plans  have  been  advised; 
those  meriting  mention  are  the  following:  (1)  Excision  and 
immediate  or  subsequent  closure  of  the  breach  by  one  of  tlie  plas- 
tic procedures;  (2)  transfixion  of  the  structure  with  heated  pins; 
(3)  inclusion  of  the  transfixed  structure  by  elastic  or  inelastic 
ligature;  (4)  cauterization  thermally,  or  potentially. 

In  case  the  angioma  occupy  a  limited  space,  the  speediest  and 
most  satisfactory  means  of  liberation  from  the  growth  is  to  excise 
it  at  once.  To  do  this,  surround  the  growth  by  a  circumscribing 
cut,  which  shall  lie  in  tlie  normal  tissue,  directly  contiguous  to 
the  growth;  thence  pass  inwards  between  the  affected  and  unaf- 
fected structures;  and  should  a  vessel  be  opened,  close  this  by 
torsion  or  ligature;  by  the  former,  if  possible.  And  then  proceed 
to  closure  of  the  breach  by  juxtaposition  through  lateral  sliding 
of  the  dermal  margins;  and,  if  possible,  this  must  be  done,  so 
that  the  line  of  closure  will  be  vertical  and  not  transverse;  for 
thus  placed,  the  movements  of  the  neck  M'ill  but  slightly  disturb 
the  wound.  In  case  direct  apposition  cannot  be  thus  affected,  a 
pedunculated  replacement-flap  can  be  uplifted  from  the  lateral 
integument,  where  the  skin  is  least  tense,  and  can  best  be  spared. 
If  the  bridge  can  not  then  be  dermally  bridged  over,  it  can  be 
accomplished  epidermally,  by  means  of  Thiersch's  method  of 
closure  by  cuticular  grafts,  in  which  elongated  strips  of  epiderm 
are  removed  with  a  razor  from  some  part  of  the  body  (by  prefer- 
ence from  the  thigh),  and  are  transplanted  on  the  raw  wound. 

Another  method  is  transfixion  with  pins,  which  may  be  thrust 
in  after  being  heated;  or  the  heat  may  be  applied  to  the  pin  after 
its  introduction  by  a  plan  that  lias  already  been  described  in  the 
section  devoted  to  angioma  seated  on  the  head.  After  such  heated 
pins  are  in  place,  they  may  be  constricted  by  elastic  cord,  by 
which  the  included  structure  will  be  strangulated.  The  cure 
obtained  in  this  way  is  objectionable,  since  it  consists  in  the 
exchange  of  the  angioma  for  an  unsightly  soar. 


BLOOD-CYST.  871 

The  treatment  by  actual  cauterization  may  be  done  by  apply- 
ing heat  to  the  surface  of  the  angioma;  but  this  superficial  appli- 
cation of  heat  is  unsatisfactory,  since  in  order  to  thus  consummate 
the  work,  the  cauterization  must  often  be  repeated.  But  should 
the  potential  cautery  be  preferred,  then  one  of  the  following  escha- 
rotics  may  be  used:  chloride  of  zinc  mingled  with  an  equal  part 
of  wheaten  flour;  potassa  fusa  mixed  with  a  similar  amount  of 
calcined  magnesia;  Emplastrum  Picis  Burgundicae,  on  each  square 
inch  of  which  there  has  been  sprinkled  one  grain  of  Antimonii 
et  Potassse  Tartras;  or  Pulvis  Ipecacuanhge  commingled  with  an 
equal  quantity  of  vaseline  may  be  applied  on  the  surface  of  the 
angioma.  By  means  of  the  first  two  agents,  the  surface  to  which 
they  are  applied  is  quickly  deprived  of  its  vitality  and  becomes 
gangrenous;  but  by  the  compounds  of  Ipecacuanha  and  Antimony, 
the  work  of  destruction  is  done  through  severe  pustulation.  The 
action  of  the  fused  potash  penetrates  deeply;  while  the  pustula- 
ting compounds  act  more  superficially;  and  all  are  subject 
to  the  inevitable  fault,  that  they  leave  a  most  conspicuous 
cicatrix. 

Blood-cyst. — Michaux  and  others  have  observed  cysts  on  the 
neck,  of  which  the  content  is  blood,  and  the  origin  of  which  is 
explicable  in  one  of  the  following  ways:  the  cyst  may  arise  from 
some  congenital  defect  of  a  blood-vessel;  or  it  may  originate  in 
an  angioma  seated  in  the  wall  of  a  vein,  and  which,  finally,  by 
pressure,  establishes  a  communication  with  the  vein;  and  also, 
a  varicose  dilatation  may  form  in  a  vein,  near  its  entrance  into  a 
larger  vein;  and  such  dilated  space  maybe  so  walled  off  as  to 
resemble  a  cyst.  And  in  whatever  way  the  cyst  may  form,  as  a 
rule  it  is  compressible  and  reducible  through  its  blood  being 
forced  into  an  adjacent  vessel;  still  there  are  exceptions  to  this, 
as  in  some  instances  observed,  the  volume  was  not  lessened  by 
compression. 

It  is  probable  that  the  blood-cyst  may,  sometimes,  arise  from 
a  cyst  of  serous,  lymphoid  or  other  fiuid  content,  through  atten- 
uation of  the  walls  and  the  consequent  rupture  of  a  neighboring 
blood-vessel,  and  the  replacement  of  the  previous  content  of  the 
cyst  by  blood. 

The  blood- cyst,  whether  appearing  congenitally  or  subsequent 
to  birth,  may  remain  of  limited  proportions;  or  it  may  grow 
until  it  reaches  great  dimensions,  and  covers  a  large  space,  whicli 
may  encroach  on  the  thorax  below,  or  on  the  head  above.  The 
skin  is  usually  not  implicated  in  the  growth.     Such  tumor  may 


872  TUMORS    OF    THE    NECK. 

cause  110   inconvenience,  yet  when  voluminous  and  near  some 
vessel,  it  has  caused  much  trouble  by  pressure. 

The  modes  of  treatment  employed  have  been  total  excision, 
the  injection  of  some  coagulating  agent,  or  coagulation  induced 
by  the  introduction  of  a  heated  needle  into  the  cyst.  Total  excis- 
ion is  the  best  method,  provided  the  anatomical  conditions  are 
such  as  will  permit  of  the  entire  removal  of  the  cyst.  A  less 
radical  method,  if  the  tumor  has  no  vascular  connection  or  outlet, 
is  to  attempt  coagulation  by  injecting  into  the  cyst  tincture  of 
iodine,  tincture  of  nut-galls,  or  a  solution  of  a  salt  of  iron.  Should 
the  cyst  have  a  connection  with  a  vessel,  then  this  method  of 
coagulation  is  hazardous,  as  the  clotted  blood  might  enter  the 
circulation,  and  become  the  agent  of  embolic  occlusion;  in  such 
cases  the  choice  would  lie  between  non-interference,  or  a  perilous 
extirpation. 

C  yst-like  collections  of  blood  may  arise  from  external  violence, 
through  which  a  vein  or  artery  is  rujDtured  subcutaneously;  and 
afterwards,  the  channel  of  communication  becomes  closed.  Such 
cyst,  when  small,  disappears  through  absorption;  but  if  larger, 
the  content  may  be  aspirated,  and  the  cystoid  space  closed  by 
compression. 

Cystic  tumor  of  parasitic  origin  has  appeared  on  the  neck,  the 
causal  agent  being  echinococcus;  and  the  site  of  the  growth  was 
the  sides  of  the  neck,  and  never  directly  in  front,  or  behind. 
This  lateral  location  points  to  the  probable  fact  that  the  causal 
agents  have  reached  the  region  through  the  large  vessels  on  the 
neck,  and  then  entering  the  smaller  vessels  have  thence  penetrated 
into  the  tissues,  in  which  they  further  developed. 

The  echinococcus  cyst  has  been  known  to  attain  great  dimen- 
sions on  the  neck,  and  to  cause  serious  trouble  through  pressure 
on  the  vessels  and  nerves;  in  the  case  reported  by  Dixon,  the 
tumor  so  pressed  on  the  subclavian  artery  where  it  crossed  the 
first  rib,  that  the  circulation  in  the  vessel  was  arrested;  and  as 
result  of  this,  the  pulse  disappeared  at  the  wrist.  And  in  another 
patient  the  growth  developed  upwards,  and  encroached  on  the 
pharynx. 

The  content  may  be  transparent,  yet  it  may  be  mingled  with 
pus.  A  characteristic  of  the  tumor  is  that  it  may  suddenly  grow 
rapidly,  and  then  cease  for  a  period,  and,  afterwards,  start  into 
activity  again.  Usual  qualities  of  the  tumor  are  the  absence  of 
albumen  in  the  fluid,  the  presence  of  benzoic  acid,  and  of  frag- 
ments and  booklets  of  the  parasite;  tiiese  booklets,  discoverable 
by  the  microscope,  definitely  decide  the  nature  of  tiie  tumor. 


SOLID    GROWTHS    OF    THE    NECK.  873 

This  tumor  is  commonly  painless,  and  if  it  remains  small,  it 
may -be  borne  without  inconvenience;  yet  when  voluminous, 
there  is  danger  that  it  may  press  on  a  vessel,  and  opening  its 
wall,  serious  bleeding  can  thus  occur.  Boegonhold  reported  a 
case  of  fatal  hsemorrhage  thus  arising. 

Treatment. — The  usual  treatment  is  excision  and  enucleation 
of  the  cyst;  or,  what  is  safer,  the  cyst  may  be  opened  by  an  inci- 
sion, and  then  the  sack,  separating  itself  from  the  neighboring 
structures  by  suppuration,  may  be  more  safely  removed  than  if 
directly  dissected  out  with  the  knife ;  in  the  latter  way  there  is 
more  peril  of  opening  a  vessel. 

Solid  Growths  of  the  Neck. — The  lymphatic  glands  are  the 
frequent  site  of  neoplastic  development;  and  these  may  be  benign 
or  malignant  in  nature. 

Simple  hypertrophy  of  the  cervical  glands,  which  may  be 
named  benign  lymphoma,  is  a  phenomenon  familiar  to  both 
physician  and  surgeon;  let  there  be  a  lesion  of  the  derm,  mucous 
membrane  or  intervening  structures  of  the  neck,  which  is  attended 
by  suppuration  for  a  few  days,  and  there  will  occur  a  swelling  in 
one,  or  several  of  the  lymphatic  glands,  which  are  near  the  site  of 
lesion.  If  such  gland  could  be  microscopically  examined,  the 
enlargement  would  be  found  to  be  due  to  a  multi^^lication  of  the 
glandular  elements.  The  tumor  is  painless,  and  even  in  the 
observing  adult,  it  may  long  remain  unknown  unless  it  be  acci- 
dentally discovered  by  the  subject  of  it,  or  by  his  physician. 

Such  hyperplased  glands  which  have  arisen  from  simple  puru- 
lent irritation,  may  remain  of  constant  volume  for  a  number  of 
days,  or  even  weeks;  and  then  they  usually  vanish  without  sup- 
puration. Should  the  causal  agency  be  of  tubercular  nature,  or 
should  the  local  lesion  be  associated  with  a  tubercular  diathesis, 
then  the  prospect  of  an  early  disappearance  is  less  promising;  for 
in  such  cases,  suppuration  and  perforation  of  the  skin,  are  the 
usual  events. 

The  sovereign  remedy  for  the  hypertrophied  glands  of  the 
neck  is  iodine  given  internally,  and  applied  externally.  As 
external  application,  iodized  collodion,  previously  referred  to  in 
this  work,  is  one  of  the  best  remedies;  the  collodion  compresses, 
while  the  iodine  exercises  its  dispersive  action.  And  should  this 
method  fail,  a  resort  may  be  had  to  enucleation,  described 
hereafter. 

As  a  means  of  reducing  the  glands,  especially  when  the  enlarge- 
ment is  due  to  tubercular  disease,  the  writer  advises  the  injection 
into  the  tumor  of  the  following  mixture: — 
56 


874  TUMORS    OF    THE    NECK. 

R.     Iodoform 51 

01.  Oliva). 

Aether.  Sulph iia  3vij 

Misce. 

Of  this  inject  a  few  drops  every  third  day.  It  may  be  added  that 
Garre'  of  Tubingen  has  lately  reported  the  cure  of  a  large  number 
of  cases  of  goitre  by  this  interstitial  use  of  iodoform. 

Sarcoma  of  the  Cervical  GlancU. — The  sarcoma  may  appear  in 
an  isolated  lymphatic  gland;  or  the  disease  may  appear  simul- 
taneously in  several  glands. 

"When  an  isolated  gland  is  the  seat  of  sarcoma  the  first 
symptom  is  enlargement;  and,  if  examined,  the  characteristic 
round  cell  of  different  dimensions  will  be  found;  also  the  fusi- 
form cell  may  be  seen,  which  has  arisen  from  a  transformation  of 
the  round  cell.  The  normal  glandular  elements  may  be  entirel}^ 
replaced  by  these  round  or  elongated  cells.  The  enlarging  gland 
crowds  on  the  overlying  skin,  and  perforating  it,  an  ulcerating, 
self-producing,  and  self-destroying  neoplasm  forces  itself  into 
view.  The  self-asserting  growth  takes  possession  of  the  contig- 
uous space  around  and  underneath ;  and,  in  doing  so,  it  erodes 
and  penetrates  vessels  and  muscles:  thus  bleeding  on  a  small 
or  large  scale  can  arise.  Also,  from  lesion  of  the  vessels,  a  door 
is  opened  for  the  admission  of  sarcomatous  elements:  thence  the 
reappearance  of  the  disease  in  parts  near  by  or  remote;  yet  more 
commonly  at  some  distance  from  the  site  of  origin.  As  a  rule, 
the  immediately  adjacent  glands  are  overleaped  in  this  metastatic 
development.  Sites  of  distant  reappearance  are  the  lungs,  liver, 
spleen  and  other  remote  parts.  The  disease  commonly  ends 
life,  according  to  Winiwarter,  within  eigliteen  months.  Some- 
times, however,  the  disease  runs  a  prolonged  course  of  some 
years. 

Instead  of  confinement  to  one  point  in  its  origin,  this  glandu- 
lar sarcoma  may  appear  simultaneously  in  a  number  of  the 
cervical  glands:  a  form  that  may  be  named  multiple  sarcoma- 
tous adenoma.  And  this  may  run  a  rapid  or  a  slow  course;  and 
it  tends  to  metastatic  diffusion  similar  to  the  form  just  described. 
The  writer  has  seen  several  examples  of  this  form,  in  wliich, 
during  a  few  months,  the  glands  of  one  side  of  the  neck  became, 
almost  simultaneously,  the  site  of  sarcomatous  disease.  In  one 
case  an  attempt  at  extirpation  served  no  better  purpose  than  to 
give  the  disease  general  diffusion. 


SARCOMA    OF    THE    CEEYICAL    GLANDS. 


875 


Sarcoma  of  adenoid  origin,  in  which  sarcomatous  and  cystic 
structure  were  commingled,  has  been  seen  by  the  writer ;  in  such 
a  case  shown  in  the  adjacent  sketch  the  tumor  was  borne  by  the 
man  until  it  had  reached  a  volume  equal  to  his  head.  After  the 
removal  of  this  tumor,  it  was  found,  on  section,  to  consist  of 
adeno-sarcomatous  tissue,  in  which  were  spaces  filled  with  serum- 
like fluid.  It  seemed  to  have  originated  from  glands  in  the 
parotidean  sulcus,  behind  the  ramus  of  the  lower  jaw,  and  in  its 
development  it  had  distended  and  greatly  displaced  the  derm  of 
the  cheek  and  neck:  and  in  the  subdermal  tissue  were  numerous 
veins  of  dimensions  greater  than  the  normal  external  jugular 
vein. 


Figure  94.  Exhibiting  a  sarcomatous  tumor  successfully  removed  by  the 
writer. 

As  setiological  factor,  Konig  refers  to  slight  traumatism  near 
by  or  remote  as  causal  agency. 

The  treatment  of  these  cases  will  be  given  at  the  close  of  this 
chapter. 

Malignant  glandular  disease,  similar  to  the  forms  mentioned, 
has  been  described  under  the  liead  of  carcinoma  by  some  writers. 
Yet  these  are  pathological  types  which  decline  to  be  stereotyped; 
for  elements  which  forsake  the  physiological  domain  often 
indulge  in  ruleless  liberty  and  lawless  riot,  and  in  their  altered 


570  TUMORS    OF    THE    KECK. 

form  they  embarrass  the  diagnostician.  In  the  microscopic 
examination  of  many  specimens  of  malignant  growths,  the 
writer  has  occasionally  found  resemblances  so  close  to  both  sar- 
coma and  carcinoma  that  the  tumor  would  not  have  been  inaptly 
named  sarcoma-carcinoma.  Such  a  name  would  screen  surgeon, 
writer  and  microscopist  from  mistaking  tlie  one  form  for  the 
other,  and  would  properly  designate  those  tumors  which  the  writer 
has  occasionally  seen,  in  which  the  cell-forms  of  both  sarcoma 
and  carcinoma  coexist. 

The  glands  of  the  neck  are  often  the  site  of  secondary 
enlarsrement,  as  the  metastatic  concomitant  of  carcinoma,  sarcoma 
or  of  a  primary  syphilitic  chancre  in  the  lips,  or  a  secondary 
syphilitic  lesion  of  the  buccal  cavity. 

Carcinoma  seated  in  the  scalp,  any  part  of  the  face,  within 
the  mouth,  throat,  or  oesophagus,  or  within  the  larynx,  sooner  or 
later  infects  the  glands  of  the  neck  through  tlie  medium  of  the 
lymph-vessels  which  connect  the  affected  part  with  the  glands. 

Mammary  carcinoma  occasionally  presents  a  metastatic  tran- 
sition from  its  primary  site  to  the  glands  which  lie  in  the  lower 
portion  of  the  neck  near  the  clavicle;  in  such  cases  the  disease 
has  previously  appeared  in  the  axillary  glands,  and  in  those 
beneath  the  pectoralis  major,  near  the  clavicle.  Supra-clavicular 
glandular  affection,  as  a  consequent  of  mammary  cancer,  is  an 
omen  of  ill  import ;  such  metastasis  indicates  recurrence  which 
is  incurable.  This  glandular  infection  is  rarer  in  mammary 
sarcoma;  and  it  is  oftener  seen  in  sarcoma  arising  in  the  parotid 
gland  and  other  .structures  of  the  head. 

Syphilitic  affection  of  the  glands  near  the  chin  has  originated 
from  labial  chancre;  glandular  infection,  as  an  accompaniment 
of  constitutional  syphilis,  is  seen  in  all  the  glands  of  the  neck, 
both  superficial  and  deep;  and  such  infection,  usually  referred 
to  vaguely  as  a  manifestation  of  secondary  syphilis,  is  probably 
referable  to  some  local  secondary  lesion;  namely,  an  ulcer  or 
breach  of  surface  on  the  tongue,  floor  of  the  mouth,  palatal 
structure,  tonsil  or  phar3'nx.  A  breach  of  surface  in  any  of  the 
parts  named  seems  to  be  inoculable  by  the  salivary  or  mucous 
secretions  of  the  patient;  and  thus  through  the  lymph-channels 
the  glands  of  the  neck  may  be  tertiarly  affected. 

The  syphilitic  glands  ma}^  attach  themselves  to  the  skin,  and 
from  non-treatment  or  improper  management,  the  glands  may 
suppurate,  and  finally  perforate  the  skin.  If  permitted  to  run 
its  own  course  such  a  gland  disintegrates  from  the  center  towards 


MALIGNANT    LYMPHOMA.  877 

tlie  circumference;  and  as  it  does  so  the  broken-down  elements 
are  eliminated  through  a  fistulous  opening;  and  the  derm  around 
the  opening  becomes  of  a  purplish  color,  which  continues  long 
after  the  gland  has  disappeared  through  suppurative  or  absorp- 
tive action. 

Scrofula  or  tuberculosis  often  appears  secondarily,  and  some- 
times, primarily  in  the  cervical  glands.  Frequently  but  one  or  two 
glands  are,  at  first,  the  seat  of  enlargement;  thence  the  affection 
extends  to  adjacent  glands;  and  it  may,  finally,  appear  as  a 
nodulated  chain  of  enlarged  glands  from  the  chin  to  the  ster- 
num. The  tendency  is  to  suppuration,  though  under  appropri- 
ate treatment,  the  glands  may  be  restored  to  their  normal 
volume  without  suppuration.  When  suppuration  ensues  the 
glandular  structure  may  liquefy,  and  be  found  as  a  cheese-like 
substance;  or,  what  is  not  unusual,  the  content  is  of  a  thin, 
cream-like  consistence,  in  which  the  microscope  discovers  numer- 
ous quadrangular  crystals  of  cholesterine. 

Malignant  Lymphoma. — There  is  a  form  of  malignant  disease 
of  the  glands  of  the  neck  which  is  closely  akin  to  sarcoma;  but 
it  differs  from  sarcoma  in  this,  that  its  development  is  confined 
to  the  lymphatic  glands,  while  sarcoma  may  arise  in  any  tissue 
of  the  body,  and  invade  in  its  growth  the  contiguous  structures. 
Sarcoma  seated  in  the  neck,  and  of  glandular  origin,  has  already 
been  mentioned ;  and  a  leading  characteristic  of  the  tumor 
described  is  that  it  fastens  itself  to  the  overlying  skin  and  finally 
perforates  the  dermal  covering.  But  in  the  malignant  disease 
now  under  consideration,  the  most  remarkable  clinical  feature  is 
that  the  skin  remains  unaffected;  and,  also,  in  most  cases,  the 
containing  capsule  of  the  gland  remains,  in  a  great  measure, 
unaffected  by  the  glandular  disease. 

The  anatomical  structure  of  the  lymphatic  gland  has  been 
studied  by  Teichmann,  Kolliker,  Robin  and  others ;  and  in  the 
main,  these  structural  elements  may  be  grouped  as  follows:  the 
gland  is  contained  in  a  fibrous  capsule  consisting  of  connective  tis- 
sue; and  from  the  inner  face  of  this  proceed  trabeculated  partitions, 
dividing  the  gland  into  alveolar  spaces.  The  gland  when  en- 
larged is  often  easily  separated  from  this  wall:  and,  when  in 
the  work  of  enucleation,  the  gland  is  adherent  to  a  vessel,  or 
dangerously  near  it,  then  the  operator  may  Tvork  safely  by  merely 
incising  one  side  of  this  envelope,  when  he  is  able  to  enucleate 
the  proper  glandular  structure.  As  said,  within  this  capsule, 
and  subdivided  by  trabecular  septa,  is   contained  the  glandular 


S7S  TUMORS    OF    THE    NECK. 

substance:  a  tissue  abounding  in  nuclei  and  cells  resembling 
lymph-corpuscles;  these  elements  are  more  numerous  near  the 
outer  part  of  the  gland;  wliile  towards  the  central  portion  of  the 
gland  one  finds  a  mesh  of  blood-vessels  and  lymph-vessels. 

In  the  malignant  lymphoma,  named  also  lympho-sarconia, 
there  is  also  a  great  increase  of  the  proper  glandular  elements; 
but  the  containing  capsule  is  usually  but  slightly  tliickened, 
and  is  easily  separable  from  the  glandular  tissue.  An  exception 
to  this  was  observed  by  Verneuil,  who  saw  a  case  in  which  the 
enlargement  consisted  wholly  in  a  great  thickening  of  the  capsule; 
so  much  so,  that  he  named  tlie  growth  capsular  lymphoma.  In 
this  patient  there  were  a  number  of  sucli  enlarged  glands  in  the 
neck,  separated  by  slight  intervals. 

The  malignant  lymphoma  is  usually  soft  in  structure;  occa- 
sionally, examples  have  been  seen  in  which  it  was  hard.  In 
fact,  in  the  history  of  the  malignant  lymphoma,  though  there  be 
a  M'ant  of  unanimity  on  some  points,  yet  most  writers  agree  that 
the  disease  commences  as  a  soft  form,  and  thence  changes  to  a 
hard  one. 

In  malignant  lymphoma,  the  disease  appears  unsuspected^ 
and,  for  a  time,  unseen ;  when  discovered  it  consists  of  an  enlarge- 
ment of  one  or  more  of  the  cervical  glands;  and  these  enlarged 
glands  finally  a})pear  in  segregated  groups  on  one  side  of  the 
neck;  yet  exceptionally  the  disease  attacks  the  glands  on  both 
sides  of  the  neck.  These  masses  are  commonly  three  in  num- 
ber. In  the  soft  variety  the  enlarged  glands  are  exceedingly 
movable.  If  such  a  growth  be  removed  and  examined,  it  will 
present,  on  section,  a  grayish  yellow,  non-vascular  structure;  and 
though  less  soft,  it  resembles  the  substance  of  the  brain  of  an 
infant ;  with  the  microscope,  one  discovers  that  tlie  tissue  con- 
sists of  elements  analogous  to  those  of  the  normal  gland;  yet  the 
cells  are  increased  both  in  number  and  in  volume.  The  struc. 
ture  is  homogeneous  from  periphery  to  centre. 

In  case  the  glands  become  indurated,  they  often  excite  some 
inflammatory  action  contiguous  to  them,  so  that  they  are  less  mov- 
able than  in  the  soft  form. 

In  both  the  soft  and  hard  species,  according  to  Winiwarter, 
the  new  growth  is  from  the  preexisting  cellular  elements  of  the 
gland;  and  the  new  structure  is,  at  first,  soft,  and  afterwards 
hardens  through  conversion  into  indurated  or  fibrous  tissue. 

If  the  disease  is  behind  the  angle  of  the  lower  jaw,  the  tonsil 
becomes  involved.     Instead  of  the  affection  remaining  unilateral, 


MALIGNANT    LYMPHOMA.  879 

it,  exceptionally,  appears  on  both  sides  of  the  neck;  and  in  each 
case  the  subjacent  glands  which  lie  in  the  axilla,  in  the  mediasti- 
nal space,  and  those  about  the  tracheal  bifarcation,  finally, 
become  infected.  The  mesenteric  glands  are  next  implicated, 
and  become  so  enlarged  that  they  can  easily  be  felt  through  the 
anterior  abdominal  wall,  in  the  hypogastric  and  iliac  regions. 
During  the  time  that  the  disease  is  confined  to  the  cervical  glands, 
the  patient,  who  is  in  childhood  or  mature  youth,  is  in  general 
good  health;  but  when  the  disease  penetrates  the  chest,  there 
often  arises  a  teasing  cough,  due,  probably,  to  pressure  on  the 
sensory  nerves  of  the  langs.  A  tenacious  material  is  expectorated; 
and  there  is  some  elevation  of  temperature.*' As  the  disease 
proceeds,  localized  infiltration  takes  place  in  the  lungs,  spleen 
and  liver;  and  such  infiltrate  is  texturally  similar  to  that  of  the 
affected  glands.  The  general  nutrition  is  imj^aired;  the  patient 
becomes  pale  and  listless;  his  tissues  become  soft,  flabby  and 
anasarcous;  and  there  is  often  an  ascitic  accumulation.  The 
chyle-channels  being  obstructed,  the  nutritive  materials  are 
directed  from  their  destination,  and,  as  in  enteric  fever,  they 
excite  a  diarrhoea.  The  ill  nourished  heart  fails  in  its  propulsive 
power;  and  life  commonly  ends  within  two  years,  if  the  disease 
has  not  been  arrested  by  treatment. 

After  this  enumeration  and  description  of  the  glandular  affec- 
tions that  appear  on  the  neck,  before  entering  on  the  treatment, 
something  should  be  remarked  in  regard  to  their  diagnosis,  and 
the  signs  by  which  one  class  can  be  distinguished  from  another. 

The  true  nature,  in  case  of  simple  hyperplastic  enlargement 
arising  from  some  traumatic,,  eczematous  or  other  lesion  of  the 
adjacent  surface,  is  revealed  by  a  discovery  of  »uch  lesion.  In 
the  tubercular  or  syphilitic  subject,  the  appearance  of  glan- 
dular enlargement  is  due  to  the  existing  dyscrasy,  wdiich,  if 
not  at  once  apparent,  is  discoverable  in  the  history  of  the  patient. 
If  the  case  be  one  of  sarcoma  or  carcinoma,  it  will  be  character- 
ized by  growth  without  suspension  of  development,  or  limitation 
of  volume;  and  with  a  tendency  to  invade  and  penetrate  neigh- 
boring structures;  and  finally,  to  perforate  the  skin  and  to  pre- 
sent a  mass  of  growing  and  disintegrating  tissue.  Metastasis 
may  occur  in  parts  remote,  as  well  as  in  structures  near  by. 
Before  the  disease  has  reached  these  widespread  dimensions,  its 
malignant  nature  ceases  to  be  a  matter  of  question.  But  as  an 
early  determination  of  the  disease  is  important  for  operative 
purposes,  hence,  as  aid,  a  particle  of  the  growth  may  be  extracted 


S80  TUMORS    OF    THE    NECK. 

with  a  small  harpoon,  or  special  acupuncture  needle,  and  its 
nature  determined  by  the  microscope.  The  prominent  and  dis- 
tinguishing features  of  the  malignant  lymphoma  have  been 
detailed,  and  ofifer  a  well-defined  diagnostic  picture  of  the  disease; 
to  rehearse  the  principal  of  these,  the  following  may  be  mentioned : 
the  infantile,  youthful  or  vigorous  subject,  the  softness  and  great 
mobility  of  the  glandular  tumor,  and  the  aggregation  of  these 
into  definite  groups  on  the  neck,  are  facts  sanctioning  the  diag- 
nosis of  malignant  lymphoma. 

Tlie  diagnostician  is  sometimes  held  in  doubtful  embarrass- 
ment by  the  apprehension  that  the  case  may  be  one  of  aneu- 
rismal  tumor;  for  example,  any  glandular  tumor  which  is  so 
contiguous  to  an  artery  as  to  receive  the  pulsatile  movement 
of  the  vessel  may  closely  resemble  an  aneurism.  Distinguish- 
ing aids  in  such  a  case  are  the  following:  if  the  aneuri;<m  be 
grasped  gentl}^  between  the  fingers,  it  will  swell  during  arterial 
diastole,  and,  by  pressure,  its  volume  is  reducible;  such  pressure, 
however,  should  be  done  cautiously,  lest  the  fibrinous  clots  be 
loosened  within  the  tumor.  If  the  pulsatile  tumor  be  noi:i- 
aneurismal,  it  is  not  expansible  nor  comj)ressible,  and  frequently 
it  can  be  so  moved  or  displaced  from  its  site  on  the  vessel  that 
the  pulsatile  movement  cannot  be  perceived  in  it.  Should  the 
evidence  still  be  equivocal,  there  is  a  ready  escape  from  the  diffi- 
culties in  the  use  of  the  hypodermic  syringe;  for,  as  soon  as  this 
enters  an  aneurismal  tumor,  a  fine  stream  of  red  blood  will 
escape;  but  if  it  enter  a  solid  or  semi-solid  tumor,  nothing  will 
be  seen,  unless  it  be  a  drop  or  two  of  serous  or  sanguinolent 
fluid. 

Treatment  of  the  Cervical  Glandular  Twmors. — The  treatment 
may  bo  divided  into  two  methods:  the  non-operative  and  the 
operative  or  surgical;  and  not  unfrequently  the  two  methods  are 
resorted  to  in  the  same  case;  medical  means  having  been  tried 
and  failed,  the  aid  of  the  scalpel  is  invoked. 

Certain  classes  of  these  tumors  are  amenable  to  and  sometimes 
are  curable  by  endermic  or  interstitial  treatment;  viz.,  the  syphi- 
litic glandular  enlargements  and  the  malignant  lymphoma. 

The  syphilitic  glands,  whether  due  to  contiguous  chancrous 
inoculation,  or  to  constitutional  syphilis,  are  often  reducible  by 
the  internal  use  of  iodine  and  mercury,  and  the  local  use  of  the 
tincture  or  ointment  of  iodine.  An  external  application  which 
acts  well  is  the  mixture  of  the  compound  tincture  of  iodine  and 
tincture  of  galls  before  referred  to;  this  should  be  well  painted 


CERVICAL    GLANDULAR    TUMORS.  881 

on  the  swollen  glands  once  daily.  Or,  instead  of  this  mixture, 
the  compound  of  iodized  collodion  may  be  applied.  Thus  by 
treatment,  general  and  local,  syphilitic  glandular  enlargements 
may  be  reduced,  and  deforming  scars  thus  avoided. 

Local  treatment  often  fails  to  accomplish  the  reduction  of 
scrofulous  glands,  and  some  operative  method  is  usually  resorted 
to  for  relief  in  such  cases. 

Cervical  glandular  enlargement,  due  to  some  simple  lesion  of 
surface  near  by,  is  removed  by  the  topical  use  of  iodine,  and  of 
the  iodized  preparations,  iodized  collodion  is  the  best;  and  this 
should  not  be  so  strong  as  to  blister  the  surface.  Such  weak- 
ened mixture  is  the  following:. — 

5^.     Collodii gij 

lodinii  puri gr.  xvi 

Kalii  lodidi gr-  xij 

Misce. 

Apply  with  a  camel-hair  brush  once  daily  over  the  swollen 
glands.  By  such  an  application  compression  and  absorptive 
disintegration  are  obtained,  and  diminution  of  volume  secured ; 
to  effect  this  it  is  often  necessary  to  continue  the  application  for 
some  weeks.  And  even  should  suppuration  occur,  the  tincture 
of  iodine  may  be  used  aloug  with  a  cataplasm.  In  fact,  by  the 
union  of  these  seemingly  antagonistic  means  the  writeiihas  seen 
absorption  accelerated,  and,  if  suppuration  was  not  arrested,  still 
it  was  lessened. 

The  glandular  disease  of  the  neck  in  which  internal  medi- 
cation has  won  its  chief  laurels  is  malignant  lymphoma.  It  has 
been  discovered  by  Billroth,  with  the  active  cooperation  of 
Winiwarter,  Czerny,  Israel  and  Tholen,  that  this  disease  can  be 
arrested  and  sometimes  cured  by  the  internal  use  of  arsenic. 
Long  ago  arsenic  was  given  internally  and  applied  outwardly  in 
the  cure  of  malignant  disease;  and  this  fact  led  to  recent  exper- 
imentation, which  verified  the  belief  previously  existing. 

To  remain  on  the  hither  side  of  the  line  of  danger  in  the 
use  of  arsenic,  in  the  essays  with  it,  the  patient  was  ordered  at 
first  a  small  dose,  and  then  to  gradually  increase  the  dose  ;  and 
along  with  it  some  gave  a  preparation  of  iron  or  some  bitter 
tincture.  Fowler's  solution  was  the  form  in  which  the  arsenic 
was  administered.  The  dose  must  be  graduated  to  the  age  of 
the  subject.  If  a  child,  commence  with  one  drop  of  the  solution 
three  times  a  day,  to  which  a   half-teaspoonful  of  the  wine  of 


S82  TUMORS    OF    THE    NECK. 

iron,  or  of  the  infusion  or  tincture  of  gentian  or  Peruvian 
bark,  may  be  added;  and,  if  the  patient  be  aniemic,  the  wine  of 
iron  is  the  preferable  adjunct.  If  tlie  patient  be  an  adult,  then 
the  incipient  dose  should  be  five  drops.  These  doses  in  the  child 
or  adult  should  be  continued  for  three  days,  and  then  increased  one 
drop;  and  every  third  day  the  dose  should  be  increased  thus, 
until  the  medicine  causes  some  constitutional  disturbance;  and 
this,  in  the  child,  will  probably  arise  when  the  dose  reaches 
ten  or  fifteen  drops,  and  in  the  adult  twenty  to  thirty  drops. 
The  irritant  action  on  the  constitution,  as  described  by  Tholen, 
was  as  follows:  in  one  patient  the  toxic  effects  of  the  arsenic 
were  manifested  in  an  impairment  of  sight  and  hearing.  In 
another  case  the  lymphomatous  growths  receded  very  rapidly, 
and,  as  this  occurred,  there  supervened  a  hsemophilic  or  general 
h^emorrhagic  condition,  with  sudden  enlargement  of  the  spleen  : 
and  these  conditions  rendered  the  suspension  of  the  remedy 
necessary.  In  most  cases  the  growths  were  rapidly  reduced  in 
volume,  and  such  reduction  was  attended  by  some  pain  in  the 
shrinking  structures.  Children  were  less  affected  by  the  arsenic 
than  adults;  in  the  latter,  the  prolonged  use  of  the  ar.senic  gave 
rise  to  sleeplessness  or  disturbed  sleep,  trembling  and  unsteadi- 
ness of  the  muscles;  the  patient  was  unfitted  for  mental  and 
phj'sical  exertion;  and  finally,  from  general  weakness,  loss  of 
appetite*and  energy,  the  patient  sank  into  melancholy.  The  use 
of  the  arsenic  sometimes  is  limited  to  accessions  of  remittent 
fever  of  a  mild  form ;  this  fever  appears  on  the  fourth  or  fifth 
day  of  the  administration  of  the  remedy. 

Besides  the  internal  administration,  the  remedy  was  used  by 
Winiwarter  interstitially  with  the  hypodermic  syringe.  To  do 
this,  let  the  needle  be  carefully  cleansed  on  its  surface;  for  if 
used  moistened  with  the  solution  it  is  apt  to  cause  suppuration. 
The  needle  should  be  inserted  deeply  into  the  gland,  and  a  drop 
of  the  fluid  there  deposited,  and  this  may  be  repeated  three 
times  daily.  Should  signs  of  suppuration  appear,  the  evolution 
of  the  pus  should  be  favored  by  the  use  of  warm  poultices. 

The  remedy  should  be  discontinued  when  its  atrophic  action 
has  been  obtained,  or  temporarily  suspended,  should  the  toxic 
action  of  arsenic  appear. 

Though  the  arsenical  treatment  may  cause  almost  a  total 
recession  of  the  glandular  enlargements,  yet  unfortunately  this 
reduction  is  usually  not  permanent;  as  a  rule,  after  some 
months  or  a  year  or  two,  the   disease   occurs,  and  it  becomes 


CERVICAL    GLANDULAR    TUMORS.  883 

necessary  to  repeat  the  treatment.  Though  a  complete  care  is 
exceptional,  and  despite  the  fact  that  the  remedy  causes  local 
pain,  and  a  depressing  cachexy,  yet  the  respite  which  has  been 
obtained  in  this  grave  disease  must  give  arsenic  a  distinguished 
place  among  the  therapeutic  acquisitions  of  modern  medicine. 

A'^erneuil  has  announced  some  essays  with  favorable  result  in 
the  use  of  phosphorus  against  malignant  lymphoma;  he  gave 
of  a  solution  in  oil  from  one  to  three  milligrammes  of  phosphorus 
daily. 

The  observation  was  recorded  by  Winiwarter  that  malignant 
lymphoma  may  recede  under  the  action  of  erysipelas  which  has 
invaded  the  affected  parts ;  and  an  attack  of  articular  rheuma- 
tism has  had  a  similar  effect.  And  carcinoma  has  vanished  in 
the  same  way.  Be'rard  mentions  a  malignant  tumor  in  the 
neck  which  quickly  disappeared  under  an  attack  of  erysipelas, 
yet  it  soon  afterwards  reappeared.  And  Reclus  has  observed  a 
patient  in  whom  a  malignant  lymphoma  quickly  receded  under 
an  attack  of  er3^sipelas  on  the  arm;  yet  the  permanency  of  the 
cure  remained  undetermined,  since  the  patient  died  from  the 
erysipelas.  The  facts  here  cited  are  suggestive  of  the  probable 
efficacy  of  the  injection  of  the  dilute  culture  of  erysipelas  in  the 
treatment  of  malignant  lymphoma. 

Mention  should  be  made  of  other  means  of  treatment  of  the 
cervical  lymphoma,  whether  benign  or  malignant;  and  among 
these  electrolysis  deserves  prominent  notice.  The  electrical 
treatment  has  been  tried  and  commended  by  Schuster,  Adams, 
Duchenne  and  others.  Duchenne  found  it  to  act  the  best  in 
cases  in  which  the  glandular  enlargements  are  small,  movable 
and  superficial.  Demarquay  is  an  ardent  champion  of  this 
treatment;  he  claims  that  failure  to  thus  cure  is  rare.  As  a  rule 
the  enlargement  simply  vanished;  but  in  a  few  cases  suppura- 
tion was  excited. 

For  a  time  the  galvanic  or  constant  current  only  was  used , 
later  Meyer  advised  the  employment  of  the  interrupted  current. 
Generally  the  electricity  was  transmitted  from  the  surface  of  the 
skin;  a  few  applied  the  current  directly  through  needles  which 
penetrated  the  tumor.  Meyer,  who  used  the  interrupted  current, 
reports  some  remarkable  results  by  the  employment  of  a  very 
strong  current;  by  this  means  he  claims  to  have  sensibly  reduced 
the  tumor  within  a  minute  or  two.  The  reports  are  sufficiently 
favorable  of  the  action  of  electrolysis  in  the  reduction  of  adenoid 
growths  to  justify  its  trial  in  such  disease. 


884  TUMORS  OF  THE   NECK. 

Trial  has  been  made  of  massage,  or  rhythmical  compression, 
in  the  treatment  of  these  affections;  or  in  place  of  interrupted 
compression,  continued  pressure  has  been  employed.  Larrey 
and  Recamier  have  recommended  this  plan.  Kneading  may 
be  done  with  the  hand ;  but  if  continued  pressure  is  emj)loycd^ 
this  may  bo  done  by  means  of  compressed  or  ordinary  sponge, 
whicli  is  retained  in  place  by  a  bandage,  adhesive  stri{)S  or  some 
clasping  and  fixing  instrument,  of  which  one  branch  rests  on, 
and  presses  the  sponge  or  lint  against  the  enlargement.  Such 
pressure  must  be  watched,  lest  it  be  carried  to  the  extent  of  caus- 
ing sloughing  of  the  integument.  Massage  was  used  by  Baudens 
as  a  means  to  loosen  the  tumor,  and  thus  facilitate  the  operator 
in  his  work  of  removing  it. 

Malgaigne,  Velpeau  and  others  have  practiced  subcutaneous 
laceration  or  discision  of  tlie  gland  by  means  of  a  fine  needle, 
which,  being  inserted  in  it,  was  twirled  about  so  as  to  divide  the 
glandular  structure  in  different  directions.  Suppuration  was 
sometimes  induced  in  this  way. 

Cauterization,  thermal  and  potential,  has  been  advised  in 
the  treatment  of  glandular  enlargements.  Verneuil  advocates 
thermal  cauterization,  done  either  on  the  surface  or  by  igni- 
puncture,  in  which  heated  points  are  thrust  into  the  enlarged 
gland.  Potential  cauterization  has  been  practiced  by  IMaison- 
neuve,  who  applied  the  escharotic  peripherally  or  centrally.  For 
central  cauterization  he  made  a  mixture  of  chloride  of  zinc  and 
flour,  wiiich,  being  cut  into  arrow-shaped  bodies,  were  thrust 
through  incisions  in  the  skin  into  the  gland.  By  this  plan  sec- 
tions of  the  glands  were  destroyed;  and  also  atrophic  contraction 
was  induced  in  tlie  portion  which  remained.  A  serious  objec- 
tion obtains  against  tlie  treatment  by  cauterization,  in  the  fact 
that  it  is  painful  and  entails  deforming  scars  of  the  surface.   ■ 

The  use  of  one  of  the  several  methods  which  have  been 
described  will,  sometimes,  cure  the  benign  glandular  tumor;  and 
may  be  tried  in  patients  whose  lack  of  courage  forbids  the  use  of 
the  knife,  or  in  whom  the  cure  by  non-operative  measures  is 
desirable;  but  in  a  large  number  of  cases,  viz.,  in  most  malig- 
nant growths,  and  in  a  number  of  the  benign  class,  the  aphorism 
of  Sanctorius  is  the  proper  rule  for  guidance;  strumous  or  glan- 
dular tumors  will  never  be  cured  unless  they  be  extirpated. 

Writers  under  the  exclusive  inspiration  of  patriotic  national- 
ity have  claimed  for  their  countrymen  the  honor  of  originating 
the  method  of  excision  in  the  treatment  of  the  cervical  alandu- 


CERVICAL    GLANDULAR    TUMORS.  885 

lar  tumor.  Thus  Gillette  claims  this  palm  for  Petit,  Chopart, 
Desault,  Dupuytren  and  Begin;  esjiecially  for  the  latter  two. 
The  impartial  writer,  however,  will  find  that  besides  the  Gallic, 
Anglican  and  American  surgery  has  claims  which  would  com- 
mand recognition  in  such  an  international  court  of  adjudication. 
The  surgeon  who  approaches  the  cervical  field  should  be 
warned  that  his  presence  there  will  only  be  justified  by  the  pos- 
session of  certain  natural  gifts:  coldness,  intrepidity,  skill,  self- 
possession.  Such  being  the  requisites,  they  are  acquisitions  possi- 
ble to  those  who,  Mezentius-like,  will  hold  close  communion  with 
the  cadaver:  one  who  has  sacrificed  uncounted  and  innumerable 
hours  in  the  dissecting  room,  will  fearlessly  penetrate  and  sepa- 
rate the  anatomical  structures  of  the  neck,  even  though  they  be 
pathologically  entangled  and  confused. 

The  surgical  strategist,  when  he  proposes  to  invade  an}'-  region, 
should  first  mentally  recount  the  anatomical  elements  which 
exist  there;  and  those  structures,  which  are  vitally  important 
and  will  be  imperiled,  should  be  noted  in  memory  by  ever  visible 
warning  marks;  thus  proceeding,  with  a  moderate  share  of  manual 
skill,  the  surgeon  makes  his  way  safely  among  the  apprehended 
impediments  of  any  region,  and  is  normally  able  to  add  another 
unit  to  the  statistician's  column  of  "  Successes." 

In  this  mental  survey  of  the  topography  of  the  neck,  the 
operator  will  remember  that  the  external  jugular  veins  lie  near 
the  skin,  and  may  be  shunned  by  cuts  in  the  long  axis  of  the 
neck;  but  transverse  incisions  will  endanger  the  veins:  a  danger, 
however,  which  can  be  obviated  by  double  ligation  and  inter- 
mediate section  of  the  vein.  Superficial  nerves,  viz.,  the  branches 
of  the  superficial  cervical  plexus  which  rest  on  or  near  the  upper 
portion  of  the  sterno-cleido-mastoid  muscle,  can  generally  be 
shunned;  the  auricularis  magnus  nerve  should  not  be  injured; 
for  this  lesion  disturbs  the  patient  through  the  ansesthesia, 
which  is  caused  in  the  integument  of  the  pinna.  The  spinal 
accessor}^  pierces  or  passes  behind  the  upper  third  of  the  sterno- 
cleido-mastoid  muscle,  and  its  section  will  leave  the  trapezius 
muscle,  which  it  supplies,  functionless. 

The  sterno-cleido-mastoid  muscle  has  frequently  been  divided 
without  much  detriment  to  the  subject;  and  even  a  large  jDart  of 
the  muscle  has  been  sacrificed  bj'  the  writer,  in  the  extirpation  of 
malignant  growths,  without  ill  consequence.  The  division  of  the 
omo-hyoid  muscle  has  also  given  no  inconvenience. 

As  the  knife  penetrates  deeper,  and  passes  from  the  median 


SS6  TUMORS    OF    THE    XECK. 

line  laterally,  the  following  structures  will  be  met:  the  laryngo- 
tracheal tube  and  thyroid  body;  the  superior  and  inferior  laryn- 
geal nerves;  the  latter  13'ing  in  tlie  grove  between  the  trachea 
and  the  oesophagus;  the  carotid  artery,  the  pneuniogastric  nerve 
and  the  internal  jugular  vein;  and  behind  this  vasculo-nervous 
group  lie  tlie  sympathetic  nerve  and  its  three  ganglia,  which  have 
connection  with  the  heart.  On  the  side  of  the  larynx  and  hyoid 
bone,  besides  the  external  carotid  and  its  branches  lie  numerous 
veins  of  large  calibre;  also  the  hypoglossal  nerve.  In  the  lower 
part  of  the  side  of  the  neck  lie  the  confluent  roots  of  the  brachial 
plexus;  and  on  the  anterior  face  of  the  scalenus  anticus  muscle 
lies  the  phrenic  nerve,  which  enters  the  chest  between  the  subcla- 
vian artery  and  vein.  The  subclavian  artery,  arch-like,  appears 
on  the  lower  part  of  the  side  of  the  neck.  This  subclavian 
arch  in  different  subjects  has  a  varying  height  above  the  clavicle; 
a  variation  that  has,  sometimes,  led  astray  the  searching  scalpel. 

The  deep  portion  of  the  cervical  region  is  separated  from  the 
thoracic  cavity  by  a  thin  pleural  septum;  a  partition  which  must 
not  be  forgotten  in  the  hazardous  excavations  sometimes  made 
here  to  enucleate  glandular  neoplasm.  Such  a  perforation 
announces  itself  by  a  whispering  or  hissing  sound  of  air  rushing 
to  fill  the  vacuum  arising  in  the  inspiratory  act.  Tlie  breach,  if 
accidentally  made,  may  be  occluded  by  lateral  displacement  of 
some  contiguous  tissue. 

Though  the  structures  enumerated  are  so  important,  yet  their 
loss  can  be  tolerated  provided  the  destruction  be  limited  to  one 
side.  Duplication  of  structure,  here  as  elsewhere,  becomes  an  ally 
in  the  continuance  of  life.  Vessels  have  been  closed  by  ligation, 
both  arteries  and  veins,  and  even  sections  of  them  excised  in  the 
removal  of  malignant  growths,  and  yet  no  serious  trouble  followed. 
The  pneumogastric  and  the  phrenic  nerves  have  been  destroyed 
on  one  side,  and  life  still  continued;  nevertheless,  though  patients 
have  tolerated  such  mutilation  of  nerves,  yet  it  should  be  avoided; 
for  it  is  safe  to  conclude  that  if  death  follow  the  destruction  of 
the  vagus  and  phrenic  on  both  sides,  their  unilateral  destruction 
cannot  be  an  unimportant  assault  on  the  organism. 

The  vessels  must  be  sedulously  cared  for;  and  the  veins 
demand  a  greater  share  of  this  care;  since  a  large  one  being 
opened,  not  only  may  death  occur  from  the  escape  of  blood,  but 
also  from  the  aspiration  of  air  into  the  vessel.  This  latter  danger 
was  long  ago  observed,  and  many  explanations  of  the  fact  have 
been  offered.     The  first  impression  was  that  the  air  contained  some 


CERVICAL    GLANDULAR    TUMORS.  887 

toxic  principle;  this  has  been  abandoned,  and  replaced  by  the 
theory  that  the  air  admitted  into  the  right  heart  expands  there, 
so  that  ventricular  closure  is  prevented;  others,  however,  claim 
that  the  air  mingles  and  forms  with  the  blood  a  gaseous  emul- 
sion, which  entering  the  lungs  interrupts  the  current  of  blood, 
and  fatal  asphyxia  thence  results.  And  like  the  fish  which 
drowns  itself  when  trying  to  escape  from  the  angler's  hook,  so 
the  victim  of  aspirated  air  dies  from  too  much  air  in  his  lungs. 

It  should  be  stated  that  Pirogoff  asserts  that  the  danger  of 
death  from  air  entering  a  vein  is  much  exaggerated;  in  fact,  in 
experiments  on  animals,  he  states  that  a  large  amount  of  air  can 
be  tolerated  if  it  be  admitted  slowly.  Few  share  Pirogoff 's  opin- 
ion that  air  in  the  veins  is  not  dangerous:  authority  is  united  in 
teaching  that  it  should  be  shunned  as  an  element  of  extreme 
peril.  In  vivisective  experimentations  E.  S.  Cooper,  of  San 
Francisco,  was  accustomed  to  show  his  students  the  fatal  action 
of  air  thrown  into  the  vessels;  and  as  means  of  relief,  he  with- 
drew with  the  same  instrument  the  air  which  he  had  introduced, 
when  the  dog,  which  the  experiment  seemed  to  have  killed, 
quickly  rallied,  and  was  none  the  worse  for  the  surgical  lesson 
which  he  had  taught. 

As  preparation  for  an  operation  on  the  neck,  the  patient's 
chest  should  be  somewhat  uplifted,  so  that  the  head  will  be 
slightly  retroflexed;  and  the  surface  which  is  to  be  operated  on, 
should  be  well  illuminated,  and  not  darkened  by  shadow  of 
surgeon  or  his  assistants. 

As  instruments  required  in  the  operation  are  the  following:  a 
scalpel,  blunt  retractors,  scissors,  clasp-forceps  in  number  propor- 
tioned to  the  extent  of  the  operation,  blunt  dissector,  thread, 
needles,  drainage  tube,  sponge,  antiseptic  solution  and  aseptic 
lint  or  gauze  for  dressing. 

The  primary  incision,  as  a  rule,  should  be  longitudinal  in 
direction;  in  some  cases,  the  cut  may  be  made  transversely  or 
obliquely.  AVhen  practicable,  such  cut  should  be  made  in  the 
line  of  the  normal  depression  of  the  skin:  for  example,  along  the 
anterior  margin  of  the  sterno-cleido-mastoid  muscle;  the  scarring 
is  thus  somewhat  masked.  The  initial  incision  is  best  made  as 
an  uninterrupted  cut,  which  is  carried  from  above  downwards, 
and  should  pass  over  the  summit  of  the  tumor.  It  should  be 
long  enough  to  permit  of  complete  exposure  of  the  growth;  and 
will  be  best  made  when  the  derm  is  divided  by  one  stroke;  for 
such  a  wound  permits  of  perfect  marginal  coaptation  and  reunion, 


888  T^•^r()RS  ok  thk  neck. 

and  leaves  a  vanishing  scar.  One  incision  often  suffices;  but  if 
the  tumor  be  a  large  one,  two  parallel  cuts  some  distance  asunder 
•U'ill  facilitate  the  extirpation;  for  through  the  two  incisions  which 
include  the  growth,  the  dissection  can  penetrate  alongside  of,  and 
beneath  it;  and  through  one  lateral  cut,  the  fingers  can  enter,  uplift 
and  thrust  the  tumor  out  through  tlie  other  incision.  Also,  the 
dissection  can  be  pursued  on  one  side  and  tlicn  on  the  other, 
with  such  alternate  displacement  as  will  bring  the  subjacent 
structures  to  view.  In  case  the  glandular  growth  lies  beneath  the 
sterno-cleido-mastoid,  the  incisions  should  run  along  the  borders 
of  the  muscle;  and  then  through  one  incision  the  introduced 
fingers  can  force  the  tumor  upwards  and  outwards  through  the 
other  cut;  thus,  without  injury  to  the  muscle,  growths  beneath  it 
can  be  removed.  By  the  aid  of  such  parallel  incisions,  an  intact 
dermal  bridge  will  remain,  which  will  span  the  breach  which  is 
made,  and  promote  the  healing  of  the  latter  better  than  would 
integument  which  had  been  sutured. 

Incisions  of  flap-form  are  sometimes  made;  an  objection  to 
this  form  is  that  the  multiple  incisions  composing  it  do  not 
admit  of  such  accurate  coaptation  as  do  single  or  parallel  lines. 
Also,  the  angles,  wlien  included  in  sutures,  may  become  gangre- 
nous and  prolong  the  time  of  healing. 

The  removal  of  enlarged  scrofulous  glands  is  frequently 
demanded:  for  such  removal  intrusted  to  nature  is  unendingly 
tedious.  Such  diseased  glands  lie  chiefly  near  the  vessels;  and 
if  they  become  inflamed,  they  contract  adhesions  with  the  vessels, 
which  render  their  extirpation  difficult  and  perilous,  from  the 
risk  of  opening  the  vessel.  The  incision  should  reach  to  the 
capsule  of  the  gland;  and  this  being  opened,  the  gland  can  be 
enucleated  with  a  curette,  a  blunt  dissector  or  the  finger;  and, 
though  there  be  adhesion  to  a  vessel,  the  gland  can  be  loosened 
and  lifted  out  without  disturbing  the  adherent  capsule.  This 
capsule  being  left  becomes  a  bulwark  against  bleeding.  This 
enucleation  always  proves  a  longer  task  than  was  at  first  calcu- 
lated; the  removal  of  one  only  opens  to  view  another  gland;  the 
searching  index  ever  finds  new  work  for  the  scalpel,  or  safer 
curette;  and  finally,  when  the  terminal  link  of  the  glandular 
chain  has  been  reached,  there  remains  a  deep  chasm  in  the  neck, 
in  the  bottom  of  Avhich  lie  the  carotid  artery  and  internal  jugular 
vein,  bared  as  if  for  an  anatomical  demonstration.  In  this  glan- 
dular excision  it  is  rarely  necessary  to  ligate  vessels;  veins  are 
oftener  wounded  than   arteries;  and   when   these   are   of  some 


CERVICAL    GLANDULAR    TUMORS. 

calibre,  they  should  be  doubly  tied  and  intermediately  divided. 
The  internal  jugular  vein  is  more  endangered  than  the  carotid 
artery,  since  during  the  struggles,  and  expiratory  efforts  of  the 
patient,  the  vein  becomes  turgidly  swollen  with  blood;  and  in 
this  state,  a  frightful  flood  of  blood  will  follow  its  rupture.  Such 
a  wound  of  the  vein  was  treated  by  Wattmann  by  lifting  up  the 
wall  of  the  vein  around  the  breach,  and  tying  this:  a  procedure 
known  as  parietal  ligation.  From  the  possibility  of  this  proced- 
ure leading  to  the  formation  of  a  clot  in  the  vessel,  it  has  had  but 
few  advocates.  Veins  which  are  entirely  divided,  sometimes 
retract  so  as  to  temporarily  cease  to  bleed;  and  afterwards,  when 
the  patient  makes  an  expiratory  effort,  the  bleeding  may  begin 
again;  and  in  such  case,  it  is  often  difficult  to  find  and  seize  the  vein 
in  its  retreat:  hence  to  avoid  such  difficulty,  the  operator  should 
tie  before  cutting  the  vein;  or  what  answers  as  well,  seize  the 
vein,  before  cutting  it,  with  forceps,  and  then  apply  torsion  to  both 
ends. 

Should  a  large  vein  be  opened  into  which  air  might  be  aspi- 
rated, the  surgeon  should  instantly  close  the  breach  with  his 
finger;  and  then,  while  compression  is  being  made  on  the  vein 
on  the  cardiac  side,  the  vessel  may  be  sought  for  and  ligated. 
A  precautionary  measure,  which  the  writer  has  resorted  to,  is  to 
have  an  assistant  maintain  constant  pressure,  after  the  vessels 
are  reached,  on  the  lower  part  of  the  neck  above  the  clavicle; 
such  pressure  will  prevent  the  admission  of  air  into  an  opened 
vein. 

In  the  treatment  of  the  malignant  lymphoma,  as  before  stated, 
internal  medication  is  chiefly  to  be  depended  on ;  yet  from  the 
writer's  experience,  he  is  convinced  that  the  scalpel  may  be  a 
valuable  ally  of  the  arsenic  which  is  given  internally.  After  the 
enlarged  glands  were  removed  in  a  t^^pical  case  of  malignant 
lymphoma,  the  internal  medication  was  continued  for  some 
time:  some  five  years  afterwards,  when  the  girl  was  reaching 
puberty,  the  disease  reappeared  on  the  neck,  and  was  treated 
similarly  without  subsequent  return  of  the  affection.  The  opera- 
tion in  such  a  case  is  a  simple  one,  since  the  glands  are  usually 
movable,  and,  as  soon  as  the  containing  capsule  is  open,  the  gland 
can  be  isolated  from  the  latter  and  removed  with  the  loss  of  but 
few  drops  of  blood. 

The  removal  of  the  sarcomatous  or  carcinomatous  glandular 
tumor  is  often  one  of  the  most  difficult  pieces  of  surgical  work; 
especiallv  if  the  tumor  has  already  attained  large  dimensions. 
57 


890  TUMORS    OF    THE    NECK. 

During  the  earh'  period  of  its  growth,  the  sarcomatous  glandular 
tumor  is  movable,  and,  at  that  time,  its  extirpation  is  not  diffi- 
cult. The  work  can  be  done  in  the  manner  described  for 
removal  of  the  benign  glandular  growth.  If,  however,  such 
tumor  lias  been  neglected  until  it  has  formed  adhesions  with 
the  adjacent  muscles  and  vessels,  and  become  immovably  fixed 
to  the  deep  structures  of  the  neck,  tlien  the  removal  becomes  a 
laborious  task,  in  which  the  blood-vessels  must  be  severely 
guarded,  while  dissection,  proceeding  stroke  by  stroke,  accom- 
plishes the  work  of  removal;  and  this,  to  be  a  benefit  to  the 
patient,  must  be  complete;  for  incomplete  excision  not  only 
weakens  the  patient,  but  opens  the  way  for  a  speedy  return  of 
the  disease.  The  subject  of  malignant  disease  can  ill  lose  blood; 
all  loss  of  this  must  be  watchfully  avoided.  To  do  this,  initial 
steps  should  be  taken  to  seek  the  artery  on  the  cardiac  side,  and 
the  vein  on  the  distal  side,  of  the  tumor;  and  if  one  or  both  be 
inextricably  adherent  to  the  growth,  then  ligation  should  be  done; 
and  this  accomplished,  the  operator  proceeds  cito,  into  etjucunde 
with  his  work  in  almost  bloodless  tissue. 

If  the  dimensions  of  such  a  growth  be  such  that  it  reaches 
below  into  the  thoracic  cavity,  or  above,  it  has  involved  the 
structures  which  emerge  from  the  foramen  lacerum,  or  it  penetrates 
the  carotid  canal  of  the  cranium,  then  the  operation  should  not  be 
done,  since  it  can  have  no  other  eff"ect  than  the  immediate  destruc- 
tion of,  or  the  abridgment  of,  life.  Such  unfortunates  should  be 
told  that  they  have  a  kindlier  friend  in  the  poppy  than  in  the 
scalpel;  the  acquisition  of  the  opium  habit  will  serve  as  a  dis- 
traction during  the  brief  remainder  of  their  existence;  and 
instead  of  shortening,  it  will  probably  lengthen  life. 

The  wound  should  alwaj^s  be  so  situated  that  the  excreta 
eff'used  into  it  will  have  free  escape,  both  in  the  sitting  and  the 
recumbent  posture.  In  some  cases  the  wound  may  be  entirely 
closed,  and  the  way  or  ways  for  drainage  then  are  made  through 
the  sound  contiguous  derm.  If  the  mouth  of  the  wound  be  on 
the  inner  side  of  the  sterno-cleido-mastoid  muscle,  it  may  be 
closed,  and  a  drainage  tube  passed  underneath  the  muscle,  and 
carried  through  the  surface  beyond.  Thus  done,  the  tube  will 
lie  on  the  vessels  and  must  not  be  allowed  to  remain  there  long, 
lest  it  erode  or  injure  the  coats  of  the  vessels;  and  to  avoid  this, 
the  tube  should  be  withdrawn  somewhat,  on  the  third  day,  and 
shortened.  The  dressing  should  consist  of  lint  moistened  with 
an  alcoholized  lotion. 


CERVICAL    GLANDULAR   TUMORS.  891 

In  the  nucha  or  posterior  structures  of  the  neck  neoplastic 
developments  occur,  which  are  of  non-glandular  origin,  and 
beuign  in  nature ;  such  tumors  are  the  lipoma,  fibroma,  and  the 
osteoma. 

The  lipoma  is  of  the  most  frequent  occurrence,  and  commonly 
occupies  the  median  part  of  the  nucha.  The  normal  capsular  wall 
of  the  lipomatous  tumor,  so  well  defined  elsewhere,  is  commonly 
not  distinctly  formed  on  tlie  nucha;  sometimes  it  does  not  exist, 
and  then  the  tumor  is  fused  indefinably  with  the  neighboring 
structures.  This  ill-bounded  li^^omatous  development  commonly 
abounds  in  fibrous  tissue,  so  that  texturally  it  is  denser,  harder, 
firmer,  and  less  movable  than  the  normal  lipoma;  and  the  fibrous 
adhesion  of  such  growth  to  the  adjacent  and  subjacent  structures 
embarrasses  the  surgeon  in  the  work  of  extirpation. 

These  adipose  neoplasms  may  be  sessile;  or,  in  development, 
they  may  project  from  the  surface  and,  through  their  massive 
form  and  weight,  acquire  a  pedunculated  form.  Such  a  pedun- 
culated tumor,  shown  in  figure  95.  was  operated  on  by  Little- 


s 

Figure  95.  In  which  is  exhibited  an  enormous  pedunculated  adipose  tumor 
arising  from  the  posterior  face  of  the  neck.  (From  Dictionaire  Encyclopedique 
des  Sciences  Medicales.) 

wood;  though  arising  from  the  upper  part  of  the  nucha,  it  was 
pendent,  and  rested  like  a  sack  of  wallet-shape  on  the  upper 
part  of  the  back.  It  w^eighed  when  removed  nearly  eight 
pounds.  In  surgical  literature  a  number  of  such  cases  have 
been  recorded,  and,  as  a  rule,  such  voluminous  growths  have 
had  deep  connection  with  the  structures  of  the  neck;  and  where 
the  growth  has  had  lateral  location   the  connections  with  the 


892  TUMORS    OF    THE    XECK." 

vessels  have  been  such  as  to  render  the  removal  a  critical  task. 
Exceptionally,  the  tumor  has  been  found  to  have  only  superficial 
connection  with  the  subcutaneous  tissue. 

The  fibrous  tissue  may  so  far  predominate  in  the  formation 
of  the  tumor  that  the  neoplasm  is  properly  named  a  fibroma; 
the  leading  characteristic  of  such  a  tumor  is  its  extreme  hard- 
ness; in  other  respects  it  closely  resembles  the  lipoma,  and,  as 
already  remarked,  the  fibrous  and  fatty  elements  may  so  equally 
concur  in  the  structure  of  the  neoplasm  that  a  proper  title  for  it 
is  fibro-lipoma. 

These  growths  cause  no  pain,  and  become  only  sources  of 
inconvenience  when  their  volume  interferes  with  the  dress  of  the 
patient's  neck;  or,  from  dragging  or  encroaching  upon  the 
lateral  structures  of  the  neck,  they  interfere  with  the  freedom  of 
the  circulation.  And  when  the  tumor  attains  large  dimensions 
it  may  interfere  with  the  recumbent  posture  of  the  subject. 

An  osteoma  may  arise  in  the  nucha,  and  has,  as  starting 
point,  the  spinous  or  transverse  process  of  a  cervical  vertebra- 
Such  crrowth  seldom  reaches  a  size  which  is  eitlier  a  marked 
deformity  era  source  of  trouble  to  the  patient;  should  it  do  so, 
it  maybe  removed  by  means  of  scalpel,  chisel  and  mallet;  or 
when  the  growth  has  been  freed  from  the  soft  parts,  if  it  be 
pedunculated,  it  may  be  excised  by  means  of  a  resection-saw  or 
chain-saw. 

The  extirpation  of  the  lipoma  or  fibro-lipoma,  when  situated 
elsewhere  on  the  body,  is  the  simplest  of  surgical  operations,  but 
when  seated  on  the  back  of  the  neck,  the  task  becomes  much 
more  difficult.  In  the  first  place,  some  effort  is  reciuired  to 
place  the  j^atient  so  that  the  growth  is  accessible  to  the  knife. 
The  patient  must  lie  nearly  prune,  with  the  breast  somewhat  ele- 
vated, and  the  head  inclined  forwards,  positions  difficult  to  main- 
tain in  the  anaesthetized  suliject.  The  patient  lying  in  position, 
a  vertical  incision  is  to  be  made,  and  the  growth  dissected  from 
the  structures  in  which  it  lies  imbedded.  For  this  dis.section  a 
scalpel  with  thick,  strong  blade  and  large  handle  is  needed.  In 
the  deeper  part  of  this  dissection  blood-vessels  will  be  met,  which 
should  be  ligated,  for,  if  not  tied,  they  will  continue  to  bleed, 
since  they  lie  in  tendino-muscular  structures,  which  interfere 
with  their  normal  contraction.  A  case  remains  vivid  in  the 
writer's  memory  in  which  a  neglect  to  secure  all  the  vessels  at 
the  time  of  the  operation  was  followed  by  haemorrhage  and  a 
tedious  healing  of  the   wound.     After  careful   ligation   of  the 


CARBU^X'LE,    ANTHRAX.  898 

vessels,  the  wound  should  be  closed  by  strong  sutures  passed 
deeply  by  means  of  a  long  curved  needle;  such  sutures  approxi- 
mating the  sides  of  the  wound  will  favor  healing. 

Carbuncle,  Anthrax. — The  carbuncle,  of  which  the  Greek  syn- 
onym is  anthrax,  occurs  in  several  regions  of  the  body,  yet  the 
tissues  on  the  posterior  face  of  the  neck  and  the  upper  part  of 
the  back  are  specially  liable  to  this  affection.  It  is  a  localized 
inflammation  of  the  dermal  and  subdermal  connective  tissue, 
probably  beginning  in  the  w'alls  of  the  sudoriparous  and  seba- 
ceous glands.  It  resembles  the  malignant  pustule,  and  the 
furuncle;  it  is  less  severe  than  the  former,  and  more  so  than  the 
latter,  so  that  a  carbuncle  is  not  inaptly  named  an  assemblage  of 
furuncles  or  boils. 

The  usual  site  of  the  carbuncle  is  on  the  upper  part  of 
the  neck,  where  the  nucha  merges  into  the  hairy  scalp ;  it 
commences  as  a  hard,  painful,  isolated  swelling,  in  which  the. 
affected  part  is  uplifted  above  the  surrounding  skin,  and  pre- 
sents one  or  several  A'esicles;  these  vesicles,  at  first  filled  with 
a  gelatinous  fluid,  soon  become  filled  with  pus.  If  the  cuti- 
cle be  removed,  these  pustules  will  be  found  to  penetrate 
inwards,  so  that  the  surface  has  a  cribriform  appearance.  These 
sieve-like  openings  are  the  seat  of  a  necrosing  process,  which 
penetrates  inwards  as  well  as  laterally,  so  that  tliere  is  finally 
death  of  a  considerable  extent  of  surface.  The  part  which  thus 
dies  is  only  slowly  detached,  and,  in  the  dying  mass,  small  islets 
of  living  structure  may  escape  the  gangrenous  destruction  which 
is  occurring  around  them.  The  slough  is,  at  first,  blue  or  dark, 
and  afterwards  assumes  an  ashy  gray  color.  It  has  not  much 
odor.  The  gangrenous  process  extends  sometimes  more  rapidly 
and  widely  under  the  skin  than  on  the  surface. 

The  disease  was  well  described  by  Celsus  as  follows:  "Of  tlie 
diseases  which  deeply  affect  the  body  none  is  worse  than  the 
carbuncle,  of  which  the  marks  are  the  following:  redness  of  sur- 
face, on  which  a  few  pustules  project,  and  these,  for  the  most 
part,  are  black,  yet  they  may  be  sub-livid  or  pale.  These  pus- 
tules within  are  black  and  contain  sanies.  The  body  is  dry  and 
harsher  than  usuaL  There  is  a  crust  on  and  around  it,  and  this 
is  begirt  with  inflammation.  The  skin  of  the  part  cannot  bo 
uplifted,  but  seems  to  be  attached  to  the  subjacent  parts.  Some- 
times there  is  shivering,  or  fever,  or  these  may  both  be  present. 
This  disease  seems  to  creep,  as  if  with  latent  roots,  in  the  subja- 
cent parts,  extending  sometimes  more  rapidly,  sometimes  more 


894  TUMORS   OF   THE   NECK. 

slowly.  And  while  thus  spreading,  the  surface  above  is  at  first 
palish,  then  it  becomes  livid  and  small  pustules  appear."  This 
Celsian  picture  of  the  disease  is  as  correct  as  any  w^hich  modern 
surgery  lias  sketched. 

John  Hunter  says  carbuncle  begins  almost  like  a  pimple,  and 
goes  deeper  and  deeper,  spreading  with  a  broad  base  under  the 
skin.  It  produces  a  suppuration,  but  not  an  abscess,  somewhat 
similar  to  erysipelas.  The  matter  lies  in  cells,  where  it  is 
formed,  almost  like  water  in  anasarca.  A  diffused  ulcera- 
tion on  the  inside  for  the  exit  of  matter  takes  place,  making  a 
number  of  openings  in  the  skin. 

Ludlow,  wdio  published  on  this  subject  in  1855,  found  that 
carbuncle  may  appear  at  any  time  in  life;  it  is  seen  in  early 
youth  as  well  as  in  old  age,  and  occurs  oftener  in  men  than  in 
women.  It  may  appear  without  a  warning  signal,  or  it  may  be 
preceded  by  insomnia,  headache,  vertigo,  fatigue,  loss  of  appe- 
tite, constipation  and  a  profuse  discharge  of  the  urates  in  the 
urine.  A  low  form  of  fever  usually  accompanies  carbuncle.  It 
varies  in  size  from  an  inch  to  ten  inches  in  diameter.  In  case 
of  recovery,  the  average  duration  is  seven  w^eeks. 

Prichard,  in  an  essay  on  carbuncles  read  before  the  British 
Medical  Association  in  1865,  stated  that  the  disease  was  annually 
increasing  in  England;  for  example,  in  1842  there  died  in  all 
England  but  forty-two  persons;  in  184G,  seventy-seven  died;  and 
yearly  the  numbers  of  deaths  increased  until,  in  1855,  there  were 
reported  tw^o  hundred  and  fifty-five  deaths.  The  disease  was 
nearly  three  times  oftener  among  men  than  women.  A  few 
cases  occurred  among  children,  but  none  among  nursing  infants. 
The  most  usual  sites  of  the  disease  were  the  neck,  back,  buttocks, 
and  the  extensor  surface  of  the  limbs.  Where  the  central  slough- 
ing is  slow  in  formation,  the  disease  spreads  rapidly  around  the 
affected  part,  and  this  has  been  referred  to  the  density  of  the  skin, 
which  prevents  the  exit  of  the  ichor  and  causes  its  diffusion 
underneath.  Death,  Prichard  finds,  can  occur  from  exhaustion 
caused  by  pyaemia,  also  from  tetanus,  and  thirdly  from  the 
disease  extending  into  and  affecting  some  adjacent  cavity;  thus 
the  disease  may  penetrate  into  the  pleural  cavity,  also  into  the 
peritoneal  cavity,  and,  occasionally,  into  the  intra-cranial  serous 
cavity. 

Laycock  found  that  the  disease  was  not  specific  and  could  not 
be  communicated  by  inoculation. 

James,  an  English  writer,  in  1866,  wrote  on  carbuncle.     He 


CARBUNCLE,    ANTHRAX.  895 

thinks  that  there  are  two  kinds  of  inflammation,  one  tending  to 
localized  isolation,  and  the  other  to  indefinite  diffusion.  The 
carbuncle  tends  to  circumscription,  and  appears  especially  in 
very  vascular  parts:  for  example,  on  the  neck  and  in  the  peri- 
neum about  the  urethra.  Its  ending  is  a  circumscribed  circle  of 
dead  tissue  around  the  central  point  of  origin.  Berard  found 
that  in  one-third  of  the  cases  of  carbuncle,  erysipelas  arose,  but 
modern  antisepsis  has  removed  this  from  the  Hst  of  events. 

Carbuncle  occasionally  appears  in  the  glycosuric  or  diabetic 
subject,  and  in  such  cases  the  disease  is  of  a  severe  form;  the 
carbuncle  is  then  large,  and  combined  with  the  existing  constitu- 
tional malady,  it  usually  destroys  the  patient's  life. 

Copland  says  "that  anthrax  rarely  occurs  excepting  in  habits 
of  body  evincing  more  or  less  of  cachexy  with  sanguineous  pleth- 
ora and  disorder  of  the  digestive  functions.  For  some  days 
before  its  eruption  the  patient  complains  of  anorexia  and 
increased  disorder  of  these  functions,  and  of  lassitude,  chills,  or 
shiverings.  With  the  development  of  the  tumor,  the  febrile 
commotion  increases,  and  presents  the  usual  concomitants  of 
inflammatory  fever.  If  sphacelation  takes  place,  or  if  the  ulcer- 
ation is  protracted,  the  attendant  fever  assumes  gradually  an 
adynamic  character;  and  in  delicate,  old,  or  very  cachectic  per- 
sons, it  is  nervous  or  adynamic  from  the  commencement." 

E-ichet,  in  1868,  finds  that  carbuncle  may  appear  in  different 
grades  of  severity;  and  he  warns  against  treating  all  cases  alike, 
since  difTerent  cases  demand  different  management. 

Croly  thinks  carbuncle  is  a  diphtheritic  jDroduct,  against 
which  he  advises  the  local  use  of  carbolic  acid. 

Diagnosis. — The  carbuncle  is  much  larger  than  the  boil;  if  a 
number  of  boils  were  to  arise  simultaneously  contiguous  to  each 
other,  the  condition  would  not  be  distinguishable  from  a  car- 
buncle; but  boils  appear  as  individuals  separated  by  some  space 
from  each  other;  and  the  boils  are  of  different  ages,  and,  when 
coexisting,  are  at  different  stages  of  development;  hence  these 
conditions  make  a  clear  distinction  between  the  boil  and  the 
carbuncle. 

The  carbuncle  has  often  been  confounded  with  the  malignant 
pustule  the  latter  is  a  more  severe  and  a  more  dangerous  afiec- 
tion  Malignant  23ustule  owes  its  origin  to  inoculation  with  the 
virus  known  as  cattle-poison.  Such  inoculation  may  be  direct 
from  contact  with  the  diseased  animal;  or  it  may  be  carried  from 
the  carcass  by  a  fly,  which,  by  its  bite,  infects  the  human  sub- 


896  TUMORS    OF    THE    NECK. 

ject.  Such  inoculation  speedily  produces  death  of  the  infected 
part.  Its  sites  are  the  hands  and  exposed  surface  of  the  face. 
The  infected  part  presents  the  condition  of  moist  gangrene,  and 
spreads  without  limit;  and  if  the  disease  is  not  arrested,  the 
patient  dies  within  a  few  days.  These  features  clearly  distin- 
guish the  malignant  pustule  from  the  carbuncle. 

Prognosis. — Carbuncle  is  not  a  dangerous  affection  when 
it  occurs  in  the  strong  and  otherwise  healtliy  subject;  but  in  the 
subject  whose  muscular,  digestive  and  assimilative  functions  are 
enfeebled,  and  whose  fund  of  vital  resources  has  been  curtailed 
by  spirituous  or  other  exhausting  excess,  and  also  in  the  diabetic 
subject,  carbuncle  sometimes  ends  fatally;  and  in  all  cases  in 
which  the  disease  embraces  a  large  amount  of  structure,  though 
the  patient  may  escape,  yet  he  approaches  perilously  near  to 
death. 

When  carbuncle  ends  fatally,  it  is  often  tlirough  the  disease 
reaching  some  visceral  cavity;  for  example,  the  encephalic,  the 
pleural  or  the  peritoneal. 

Treatment. — If  the  disease  be  seen  in  the  beginning,  its  prog- 
ress may  sometimes  be  checked,  and  the  disease  arrested  by  the 
hypodermic  use  of  carbolic  acid.  For  this  purpose  liquefied 
carbolic  acid  is  to  be  used;  and  to  do  this,  charge  a  Pravaz 
syringe  with  a  few  drops  of  the  acid,  and  insert  the  hollow 
needle  at  some  four  or  five  points  in  the  carbuncular  structure,  and 
inject  a  drop  at  each  point.  The  pustulated  surface  may  also 
be  cauterized  with  the  carbolic  acid.  Instead  of  this  agent  the 
compound  tincture  of  iodine  may  be  used  hypodermicaily.  In 
this  way  the  author  has  seen  the  development  of  the  carbuncle 
arrested,  and  the  patient  given  speedy  relief. 

Other  local  remedies  used  as  abortive  means  have  had  ear- 
nest advocates;  of  these  the  following  deserve  mention:  Tlieil- 
mann  treated  three  hundred  and  forty-three  cases  of  carbuncle,  of 
which  all  except  five  recovered;  his  treatment  was  simply  local 
applications,  and  consisted  of  the  following  compound:  turpen- 
tine and  spirit  of  camphor,  of  each  one  ounce,  the  yolk  of  an  egg, 
and  a  pint  of  the  decoction  of  chamomile;  and  in  some  cases- he 
gave  acids  and  camphor  internally.  Rigby  used  the  tincture  of 
icdine  externally;  Cook  used  belladonna  locally;  an  opium 
j^laster  was  used  by  Gutzeit,  the  extract  of  opium  by  Shillitoe, 
and  the  acid  nitrate  of  mercury  by  Startin. 

Early  in  this  century.  Dr.  Physic  of  Philadelphia  treated  the 
carbuncle  by  blistering;  and  in  1876  the  same  was  recommended 


CARBUNCLE,   ANTHRAX.  897 

by  J.  Guerin.  Guerin  asserted  that  by  this  treatment,  a  hard, 
tense  and  painful  tumor  was  clianged  into  a  painless  and  benign 
one.  The  blister  should  have  an  opening  through  the  centre; 
and  on  the  blistered  surface  a  cataplasm  should  be  applied. 
Guerin  thinks  the  vesication  extracts  the  virus  from  the  car- 
buncle. 

The  greater  number  of  surgeons  have  advocated  some  more 
energetic  treatment  than  the  means  above  enumerated;  such 
treatment  may  be  classified  under  the  heads  of  cauterization, 
incision,  open  or  subcutaneous,  and  excision. 

Celsus,  in  the  following  words,  advised  the  actual  cautery: 
Nothing  is  better  than  to  immediately  burn  it:  nor  is  this 
severe,  since  the  flesh  having  already  died  does  not  feel.  And 
the  burning  is  only  to  end  when  the  sense  of  pain  is  felt  in  the 
parts  acted  on.  The  force  of  the  attack  should  be  proportioned 
to  the  magnitude  of  the  disease. 

In  1821  Ph3'sic  published  the  beneficial  results  which  he  had 
derived  from  the  escharotic  action  of  caustic  potash;  he  applied 
this  as  soon  as  vesicles  appeared  on  the  skin,  and  so  destroyed  the 
latter  that  there  was  a  free  opening  for  the  escape  of  the  acrid 
matters.  In  all  cases  he  found  that  the  pain  of  the  carbuncle 
ceased  as  soon  as  the  action  of  the  potash  had  terminated.  In  1863 
Prichard  recommended  the  use  of  caustic  potash;  he  used  the 
solid  stick,  and  thrust  this  deeply  into  the  carbuncle.  To  abate 
the  pain  from  the  caustic  he  placed  on  the  part  a  mixture  of  salt 
and  ice.  On  the  remaining  diseased  surface  Prichard  painted 
the  following  mixture: — 

^.     Collodii li 

lodi. 

Potasii.  lodidi , aa  9  j 

Misce. 

On  the  cauterized  surface  Prichard  applied  resin  ointment; 
he  wholly  discarded  poultices  in  the  treatment  of  the  carbuncle. 

The  writer  has  derived  benefit  from  the  escharotic  action  of 
sulphate  of  zinc  applied  in  crystals  to  the  interior  of  the  car- 
bunculous  structure,  after  the  latter  has  been  freely  incised;  thus, 
sections  of  the  affected  structure  can  be  made  to  rapidly  slough 
off,  and  detach  themselves  from  the  sound  tissues. 

The  Celsian  plan  of  attack  with  the  actual  cautery  has  been 
employed  in  a  few  cases  by  the  writer.  For  this  purpose  use  the 
incising  point  of  the  thermal  cauter}^  and  burn  deep  furrows 


898  TUMOES    OF    THE    NECK. 

into  the  diseased  part.  Over  the  carhuiicle  tlius  furrowed,  place 
a  poultice  which  may  consist  of  boiled  chamomile  flowers,  or 
boiled  starch,  or  boiled  carrots.  Under  this  treatment  the 
detachment  of  the  gangrenous  tissues  will  be  accelerated. 

Compression  was  advised  by  O'Ferral  and  Colles:  this  was 
done  by  means  of  an  adhesive  plaster  which  contained  opium. 
Others  have  used  lead  plaster  and  collodion. 

Trelat  advises  prolonged  baths  and  dressing  with  wadding. 

The  plan  of  treatment  which  is  most  in  favor,  is  that  of 
incision;  and  yet  like  all  surgical  procedures  this  one  has  had 
its  opponents. 

One  of  the  earliest  advocates  of  treating  the  carbuncle  by 
incision  was  the  English  surgeon  "Wiseman  of  the  time  of  Charles 
the  Second,  who  wrote:  "I  advise  scarifying  or  cutting  deep  into 
it  (the  carbuncle)  to  give  a  breathing  to  the  humor."  And  he 
awakens  our  incredulity  when  he  says:  "  I  never  saw  a  true  car- 
buncle suppurate."  Free  incisions  were  practiced  by  Cooj^er, 
Abernethy  and  most  of  the  English  surgeons.  The  French  give 
to  Dupuytren  the  credit  of  ])opularizing  this  method  of  treat- 
ment. 

The  method  of  incision  has  been  practiced  in  several  ways. 
The  most  conservative  j)lan  was  that  of  (jruerin  and  Gosselin,  who 
did  the  work  subcutaneously.  They  introduced  a  narrow  bladed 
knife  through  the  skin,  and  then  twirling  the  instrument  about, 
they  divided  the  structures  circularly  around;  and  thus  a  large 
wound  is  shunned  through  which  pysemic  infection  can  occur. 
Hueter  advocates  the  method  by  subcutaneous  incision. 

In  a  discussion  of  this  subject  in  1881,  Le  Fort,  See,  Marjolin, 
LeDentu,  Boinet  and  other  French  surgeons  recommended  the 
treatment  by  incisions;  yet  some  would  limit  the  work  to  subcu- 
taneous division.  Verneuil  and  Tillaux  are  more  conservative, 
and  the  former  thinks  that  in  eighty  per  cent  of  the  cases  the 
patient  may  be  cured  without  incision.  Desprds  advocates  the 
expectant  method;  yet  his  report  of  fifty-seven  cases  which  he 
thus  managed,  and  of  which  six  died,  does  not  encourage  the 
adoption  of  his  mode  of  treating  the  disease. 

Ludlow  strongly  i)rai.ses  the  treatment  by  free  incisions;  and 
this  should  be  done  early  in  the  disease,  since  it  will  lessen  the 
pain,  and  diminish  the  development  of  the  carbuncle. 

Colles  advises  to  make  a  number  of  incisions  deep  enough  to 
divide  the  superficial  fascia;  for  he  contends  that  this  tissue 
causes  strangulation  and  death  of  the  structures  which  are  con- 


CARBUNCLE,    ANTHRAX.  899 

fined  beneath  it.  Velpeau  makes  multiple  incisions,  from  twelve 
to  fourteen  in  number,  in  case  the  carbuncle  be  of  large  dimen- 
sions. The  method  commonly  in  practice  is  to  make  a  crucial 
cut,  which  will  traverse  the  carbuncle  from  border  to  border,  and 
penetrate  quite  through  the  affected  structure.  In  such  work 
the  scalpel  will  creak  or  cry  as  if  it  were  dividing  leather. 

The  effect  of  such  free  incision  is  free,  but  not  excessive  bleed- 
ing, and  a  draining  or  "breathing  out,"  as  Wiseman  calls  it,  of 
some  of  the  morbid  elements  of  the  affected  parts.  For  a  few 
moments  the  pain  caused  by  incising  is  great;  yet  it  brings  quick 
cessation  of  the  pain  which  previously  existed.  A  free  outlet  is 
thus  made  for  the  disintegrating  and  gangrenous  carbuncular 
structure. 

After  incising  the  carbuncle,  the  breaking  down  of  the  dis- 
eased tissue  should  be  favored  by  an  anodyne  poultice;  fortius 
purpose  a  mixture  of  moist  hops  and  poppy  leaves  may  be 
applied.  As  soon  as  shreds  loosen,  they  should  be  detached  with 
forceps  and  scissors;  thus  dead  material  may  be  gotten  rid  of  at 
once,  which  otherwise  would  encumber  the  wound  for  several 
days.  Besides  the  cataplasm,  the  wound  should  occasionally  be 
cleansed  with  some  disinfectant  lotion  ;  for  this  purpose,  dilute 
chlorinated  water,  or  a  weak  solution  of  permanganate  of  potash 
may  be  used  for  cleansing  the  wound;  and  the  same  maybe 
added  to  the  cataplasm. 

The  eminent  English  surgeon,  Paget,  besides  his  opposition  to 
the  free  incision  of  the  carbuncle,  does  not  favor  the  practice  in 
use  of  giving  the  carbuncular  patient  spirituous  drinks  and 
generous  diet.  The  experience  of  the  writer  does  not  accord 
with  this  course;  the  patient  fed  to  repletion  and  allowed  wine, 
or  other  spirits,  will  do  better  than  one  confined  to  an  abstemious 
regimen.  As  internal  medication,  the  adult  may  be  given  three 
times  daily,  a  teaspoonful  of  the  compound  tincture  of  gentian, 
or  cinchona;  and  if  to  each  dose  there  be  added  a  teaspoonful  of 
pulverized  ice  and  a  half  tablespoonful  of  cognac,  the  mixture 
will  awaken  the  desire  for  other  food. 

Should  the  pain  continue  after  the  carbuncle  has  been  freely 
incised,  then  an  opiate  should  be  given:  viz.,  a  fourth  of  a  grain 
of  morphia  every  five  or  six  hours;  and  the  efficienc}^  of  this 
will  be  augmented,  if  to  each  dose  there  be  added  a  grain  of 
camphor  and  three  grains  of  quinine. 

The  ragged  breacli  in  the  nucha  will  be  slow  in  healing;  and 
there  will  remain  a  large  uneven  scar,  to  mark  the  site  of  the 
carbuncle. 


900  TUMORS   OF   THE   NECK. 

There  remain  to  be  mentioned  certain  modifications  of  the 
method  of  treatment  by  incision.  In  1SG6,  Foucher  advised  to 
lay  open  the  carbuncle,  and  then  apply  over  the  cut  surface  a 
large  suction  cup;  thus  Foucher  sought  to  extract  the  affected 
fluids  of  the  diseased  structures. 

In  18G5,  Bi-oca  announced  to  the  Society  of  Surgery,  that, 
struck  with  the  gravity  of  carbuncle,  he  had  conceived  the 
notion  of  treating  it  as  a  malignant  growth;  he  had  not,  how- 
ever, carried  out  his  idea,  since  it  is  difficult  to  foresee  the  extent 
to  which  tlie  carbuncle  may  develop.  Blackley,  an  Irish  surgeon, 
pursued  this  plan  in  one  case;  after  freely  opening  the  affected 
structure  with  the  knife,  he  then  proceeded  to  excise  the  car- 
bunculous  structure  with  scissors ;  this  done  he  replaced  the  flaps 
and  compressed  them  wdth  adhesive  strips,  and  obtained  a  speedy 
cure.  The  author  has  put  this  plan  into  partial  practice,  in  this 
way,  that  after  making  the  cruciform  incision,  he  excised  the 
diseased  structure  from  beneath  the  four  angular  sections,  leav- 
ing the  skin  as  a  covering.  Some  benefit  resulted  from  the 
excision,  since  the  sloughing  process  was  lessened,  and  there 
remained  less  diseased  structure  for  detachment. 

In  conclusion  of  this  chai)ter  upon  carbuncle,  the  writer 
would  advise  the  following  treatment  of  the  disease:  if  seen  in 
the  commencement,  endeavor  to  arrest  by  the  interstitial  injec- 
tion of  carbolic  acid;  if  seen  somewhat  later,  incise  crucially, 
and  use  an  anodyne  cataplasm ;  and  if  seen  still  later,  when  the 
tumefied  structure  is  perforated  with  gangrenous  sinuses,  then  in- 
cise crucially  or  stellately,  and  excise  the  diseased  structure  which 
is  accessible,  and  dress  with  an  opiated  ointment,  or  cataplasm. 

Malignant  Pustule. — There  is  an  affection  so  closely  cognate  to 
carbuncle  that  a  consideration  of  it  here  is  deemed  proper;  this 
is  malignant  pustule. 

This  aff^ection  commences  as  a  red  point,  which  is  but  little 
elevated  above  the  surface,  and  is  the  site  of  itching  and  prick- 
ling. Such  initial  red  points  appear  in  numbers;  the  part  swells; 
the  cuticle  is  uplifted  like  a  slight  blister;  and  the  underlying  rete 
mucosum  and  coriura  are  of  a  dark  red  or  purplish  color.  The 
dermal  tissue  has  suddenly  become  the  site  of  moist  gangrene; 
and  the  sensation  there  is  rather  that  of  tightness  and  tension 
than  of  severe  pain.  The  general  circulation  is  much  disturbed; 
the  pulse  is  small  and  often  irregular;  nausea,  vomiting,  delirium 
and  great  physical  depression  are  present.  When  located  on 
vascular  and  distensible  parts,  there  is  great  swelling.     The  affec- 


MALIGNANT    PUSTULE.  901 

tioii  has  no  tendency  to  self-limitation,  but  rather  to  indefinite 
diffusion.     If  near  the  brain  the  latter  becomes  congested. 

The  disease  is  caused  by  a  special  contagious  virus,  which  is 
developed  in  cattle,  sheep,  and  rabbits;  the  human  subject  con- 
tracts the  disease  from  such  affected  animal.  From  their  occu- 
pation, the  butcher,  skinner,  tanner  and  scavenger  are  the  most 
usual  subjects  of  malignant  pustule.  Tlie  disease  occurs  oftenest 
in  wet  weather. 

Pasteur  and  others  have  studied  the  causal  virus  and  found 
that  it  is  very  tenacious  of  existence  and  power  of  infecting: 
qualities  which  are  not  lost  by  long  burial  of  the  dead  animal. 
And  the  virulent  intensity  is  so  concentrated  that  it  remains, 
though  the  virus  be  greatly  diluted  in  water. 

The  disease  is  reported  to  have  arisen  in  man  without  actual 
contact  with  an  aiTected  animal.  This  may  be  doubted  and  has 
arisen  from  the  lack  of  accuracy  which  too  often  obtains  among 
patients  in  regard  to  their  ailments.  For  the  subject  of  grave 
disease  in  his  state  of  physical  pain  and  alarm  must  necessarily 
furnish  a  history  alloyed  with  many  errors:  errors  too  great  to  be 
sifted  out  by  the  attendant  who  is  not  a  severely  critical  analyst. 

The  use  of  the  flesh  of  animals  thus  affected  may  cause  serious 
illness;  this  probably  depends  on  whether  the  meat  has  been 
imperfectly  or  thoroughly  cooked. 

Bourgeois,  who  saw  many  cases  of  this  disease  in  France,  says 
that  he  never  saw  any  delirium  attend  it;  and  this  is  in  accord 
with  the  writer's  experience. 

The  affection  is  preeminently  a  dangerous  one,  tending 
to  death  unless  it  be  vigorously  treated  at  the  onset.  This 
depends  on  the  fact,  that  the  part  which  is  the  site  of  the  gan- 
grenous process  is  in  immediate  and  uninterrupted  connection 
with  the  adjacent  living  parts  :  no  wall  of  coagulated  proteinace- 
ous  material  is  formed  as  a  barrier  betv/een  the  dead  and  the 
living  tissues;  the  infecting  content  of  the  former  enters  and 
does  its  fatal  work  in  the  latter.  And  thus  the  diseased  area 
continually  widening,  the  ichorismic  process  is  rapidly  augmented. 

In  surgical  literature  the  malignant  pustule  has  been  con- 
founded with  the  carbuncle;  and  as  the  two  radically  differ  in 
nature  and  treatment,  it  is  necessary  to  clearly  indicate  their 
diagnostic  differences.  Carbuncle  is  more  of  a  local  trouble,  and, 
■commencing  on  the  outside,  it  penetrates  inwards;  malignant 
pustule  is  more  rapid  and  thorough  in  its  destructive  work, 
completely  killing   at    once,    the    structures   which   it  attacks. 


902  TUMOKS    OF    THE    NECK. 

Carbuncle  has,  as  its  more  special  sites  of  development,  the  neck, 
back,  and  buttocks;  but  malignant  pustule  appears  almost 
exclusively  on  the  uncovered  ])arts  of  the  body;  and  its  action  is 
limited  to  the  skin,  wliile  carbuncle  attacks  chiefly  the  subcu- 
taneous celluhir  tissue.  In  carbuncle,  the  affected  part  is  hard, 
red  and  circumscribed;  malignant  pustule,  however,  tliough  liard, 
is  pale  and  not  well  defined,  and  vesicles  appear  on  it.  Carbun- 
cle is  painful,  but  malignant  pustule  occasions  a  sensation  of 
biting,  burning  and  tension. 

According  to  Ancelon,  malignant  pustule  begins  as  a 
phlyctsena-clad  surface,  and  it  penetrates  rapidly  inwards;  from 
the  affected  focus  reddish  streaks  radiate  into  the  surroundino- 
skin;  and  as  the  disease  advances  peripherally,  the  central  part 
dying  becomes  cold  and  insensible.  A  shooting,  burning  pain  is 
felt  in  the  sinuous  border. 

Pathological  Changes  Present  after  Death. — The  slough  or  gangre- 
nous structure  of  the  surface  primarily  attacked  is  seldom  more 
than  a  line  in  thickness,  and  is  brown,  livid  or  black  in  color;  and 
the  blood-cells  contained  in  it  appear  under  the  microscope,  dis- 
integrated, and  the  blood  contains  microphytes  which  will  pres- 
ently be  considered. 

The  blood-vessels  are  lilled  with  a  black  and  liquid  blood. 
It  has  been  noted  that  the  left  side  of  the  heart  contains  but  a 
small  quantity  of  blood;  and  this  is  uncoagulated.  The  blood 
putrefies  with  the  greatest  rapidity,  and  is  found  to  contain  but 
little  fibrin.  The  serous  cavities,  as  the  pericardial  and  pleural, 
contain  a  blood-stained  serum. 

Davaine  and  Raimbert  have  made  a  microscopic  study  of  the 
fluids  of  animals  and  men  who  have  died  of  malignant  pustule, 
and  they  have  found  bacterial  corpuscles;  these  have  been  the 
su1)ject  of  nnich  experimental  research  on  the  part  of  Davaine. 
These  microphytes  are  discovered  in  the  serous  fluid  which 
intervenes  between  the  masses  of  aggregated  blood- cells;  and  in 
their  form  they  are  elongated,  rod-shaped,  smooth,  of  equal  size 
from  one  end  to  the  other;  and  are  found  floating,  or  at  rest. 
Though  generally  elongated  and  straight,  yet  sometimes  they 
are  curved,  or  bent  at  an  acute  angle.  The  blood  which  con- 
tained these  bacterial  microphytes  had  lost  its  power  of  coagu- 
lating and  the  microscopic  forms  which  existed  in  it  were  not 
destroyed  by  water  or  alkaline  fluids. 

Treatment. — Treatment  to  be  effective  should  be  commenced 
early  and  pursued  with  prompt  diligence.     That  the  disease  i'- 


CHANGES  PRESENT  AFTER  DEATH.  903 

curable  has  been  verified  several  times  in  the  writer's  experience. 

If  seen  early,  the  vesicles  must  be  opened,  and  their  content 
removed.  The  subjacent  gangrenous  surface  should  be  incised 
crucially  and  the  four  flaps  should  be  dissected  from  the  unaffected 
underlying  structure,  and  excised;  thus  one  radically  disposes 
of  the  sloughing  structure  which  is  teeming  with  the  elements  of 
the  disease.  The  dissecting  knife  should  confine  itself  to  the  line 
which  separates  the  dead  from  the  living  tissue;  thus  done,  no 
bleeding  occurs.  After  this  excision  of  the  gangrenous  structure, 
the  actual  cautery  is  to  be  applied  to  the  denuded,  as  well  as  to 
the  contiguous  affected,  structure;  the  line  of  cauterization  must 
pass  somewhat  beyond  the  vesicular  and  indurated  structure. 
The  pointed  cautery  should  be  made  to  penetrate  quite  through 
the  diseased  tissue. 

The  potential  must  reenforce  the  actual  cautery;  and  for  this 
purpose,  numerous  agents  are  at  our  service;  those  which  have 
best  repute  are  the  chloride  of  zinc,  the  chloride  of  antimony  and 
caustic  potash.  The  chloride  or  butter  of  antimony  is  preferred 
by  Enaux,  Chaussier,  Bidault  and  others.  To  use  this,  let  por- 
tions of  lint  saturated  w^ith  the  agent  be  placed  at  different  points 
of  the  affected  surface,  and  covered  with  dry  lint,  and  the  whole 
fixed  in  place  b}^  adhesive  plaster.  Caustic  potash  is  a  very 
effective  escharotic  ;  this  may  be  rendered  less  severe  b}^  mixing- 
it  with  an  equal  amount  of  calcined  magnesia  or  powdered 
Sanguinaria.  The  severe  action  of  the  potash  requires  that  some 
precautions  be  used  to  prevent  it  reaching  and  attacking  the 
adjacent  sound  parts;  for  this  purpose,  let  these  parts  be  covered 
with  adhesive  plaster.  The  writer  has  often  applied  the  caustic 
potash  in  pencil-form  as  an  escharotic,  in  cases  other  than  the  one 
here  treated  of.  For  this  purpose,  the  fused  material  fixed  in  a 
holder  can  be  applied,  and  the  tissues  destroyed  to  the  extent 
one  wishes.  The  escharotic  action  can  be  arrested  by  pouring 
water  or  olive  oil  over  the  cauterized  structure.  The  action  is 
speedy  and  attended  by  little  pain. 

In  18G4,  a  charlatan  in  France  had  wonderful  success  in  treat- 
ing the  disease;  and  his  secret,  published  at  his  death,  consisted 
in  the  application  of  pure  corrosive  sublimate  to  the  diseased 
surface.  This  salt  was  applied  to  all  of  the  surface  which  was 
the  site  of  vesicles;  the  affected  structure  was  thus  wholly 
destroyed,  and  detached  itself  On  the  part  thus  cauterized,  an 
ointment  compounded  of  styrax  was  applied. 

The  author  has  treated  several  cases  of  malignant  pustule 


904  TUMORS    OF    THE    NECK. 

which  had  been  contracted  from  dead  cattle:  the  disease  was 
commonly  on  the  hands;  j-et  in  one  case  it  was  on  the  face;  and 
the  manner  of  treatment  which  was  pursued,  and  proved  almost 
uniformly  successful,  was  as  follows:  by  ecraseur  or  scraping 
with  some  blunt  instrument,  the  vesicular  surface  is  to  be  removed; 
and  then,  if  the  subjacent  derm  has  not  become  gangrenous, 
apply  to  it  the  following  solution  of  bromine : — 

li.     Bromi 3ss 

Aquae 3  xij 

Glycerini 5iv 

Misce. 

Let  the  diseased  surface  be  well  covered  with  this,  and  then 
let  a  piece  of  lint  be  saturated  with  the  same  and  placed  on  the 
affected  site.  As  the  odor  of  bromine  is  disagreeable,  and  may 
have  a  pernicious  effect  on  the  patient,  the  dressing  should  be 
included  in  a  piece  of  oiled  silk.  If  the  disease  be  on  the  hand, 
as  is  commonly  the  case,  the  limb  should  be  flexed  and  carried  in 
a  sling.     The  dressing  should  be  removed  daily. 

Should  the  erasure  of  the  vesicular  surface  not  be  followed  by 
the  exuding  of  normal  red  blood  from  the  denuded  corium,  this 
indicates  that  the  derm  is  passing  into  gangrene ;  and  in  such 
condition  the  scraping  must  be  continued,  and  carried  deeper 
into  the  true  skin;  and  if  it  is  found  that  this  is  wholly  gangre- 
nous, then  the  dead  skin  should  be  excised,  the  subjacent  tissues 
thermally  cauterized,  and  over  this  cauterized  surface  the  dress- 
ing of  bromine  should  be  applied.  By  this  treatment,  without 
any  internal  medication,  the  writer  has  successfully  treated  sev- 
eral cases  in  which  the  disease  was  on  the  hands.  One  patient, 
in  whom  the  disease  was  on  the  side  of  the  face  and  scalp,  did 
not  recover;  it  should  be  mentioned  that  the  disease  was -far 
advanced  when  first  seen,  and  death  occurred  on  the  fourth  day. 
In  this  treatment,  if  the  patient  be  addicted  to  alcoholic  drinks, 
these  should  be  continued. 


CHAPTER  XXA^III. 


AVOUNDS    OF    THE    XECK. 


"WouxDS  of  the  neck  have  been  classified  most  diversely.  Not 
content  with  the  old  division  of  incised,  lacerated  and  contused, 
penetrating  and  gunshot  wounds,  some  have  proposed  the  classi- 
fication of  penetrating  and  non-penetrating;  others  according  to 
gravity  have  named  them  fatal  and  not  fatal.  Others  have 
adopted  a  regional  nomenclature  in  which  one  finds  the  groups 
supra-hyoidean,  sub-hyoidean,  thvroidean,  etc.,  according  to  the 
site  of  injury.  A  practical  division  is  into  superficial  and  deep 
wounds,  which  may  be  further  defined  by  mention  of  the  struc- 
tures involved. 

The  wound  ma}'  result  from  accident,  from  violence  infiicted 
by  a  criminal  hand,  or  surgery  itself  may  be  responsible  for  it; 
thus  in  tracheotomy,  oesophagotomy,  tenotom}^  and  particularly 
in  the  removal  of  growths  from  the  neck,  wounds  of  greater  or  less 
severity  are  made  by  the  surgeon. 

Dupuytren  has  observed  that  the  dress  of  the  neck  often 
protects  the  part  from  injury;  and  hence  in  winter,  when  the 
neck  is  thickly  dressed,  wounds  are  rarer  than  in  summer  when 
the  neck  is  more  exposed. 

The  superficial  wounds  may  be  longitudinal,  transverse  or 
oblique  in  direction;  and  when  transverse  the  gaping  is  thegreatest. 
If  only  the  derm  is  involved,  such  wound  is  of  little  importance; 
but  if  one  or  more  of  the  superficial  jugular  veins  be  divided, 
then  there  may  be  dangerous  bleeding;  in  one  reported  case  a 
f|uart  of  blood  was  lost,  with  the  result  of  destroying  the  patient's 
life.  Besides  haemorrhage,  aspiration  of  air  into  these  veins  has 
occurred  with  the  perils  arising  from  this  accident. 

Besides  the  gaping  of  these  wounds  alluded  to,  there  may  be 

in-roliing  of  the  borders;  and  this,  which  is  due  to  the  action  of 

the  platysma  myoides,  occurs  more  at  the  upper  part  of  the  front 

of  the,  neck  than  at  the  inferior  portion.     And  to  correct  both 

58  ~"(90o) 


906  WOUNDS    OF    THE    NECK. 

these  conditions,  the  suture,  twisted  or  knotted,  has  been  used  by 
some  surgeons;  yet  Dietfenbach  and  many  modern  surgeons, 
having  found  that  suppuration  occurred  under  such  closed 
wounds,  have  discarded  the  suture,  and  attempted  union  by 
adhesive  plaster;  in  fact,  fearing  such  suppuration,  they  have 
left  the  wound  somewhat  open.  The  writer,  however,  advises  clos- 
ure by  catgut  or  metallic  suture  after  the  wound  and  adjacent 
surface  have  been  rendered  aseptic.  And  such  stitch  should  be 
so  inserted  as  to  retain  the  unrolled  edges  aptly  united;  and  to 
accomplish  this  the  margins  should* be  everted  during  the  pas- 
sage of  the  needle.  The  surface  should  be  painted  with  the  com- 
pound tincture  of  benzoin,  covered  with  isinglass  plaster,  and  the 
whole  covered  with  cotton  wadding.  The  wu:»und  should  be 
inspected  daily,  and,  if  no  irritation  appears  in  it,  the  metallic 
sutures  may  remain  in  site  for  four  or  five  days ;  but  if  there  be 
indications  of  suppurative  action,  then  each  alternate  suture 
should  be  removed,  and  a  dressing  applied  consisting  of  lint  wet 
with  a  twenty-five  per  cent  solution  of  alcohol.  In  case  the 
suture  consist  of  catgut,  this  will  vanish  through  absorption; 
and  as  such  absorption  may  occur  before  firm  closure  of  the 
wound,  the  writer  gives  preference  to  fine  wire  as  material  for 
suture. 

Deep  or  penetrating  wounds  may  im})licate  the  nucha,  side  or 
front  of  the  neck. 

The  deeplv  penetrating  wound  of  the  nucha  is  most  frequently 
caused  by  the  sword,  sabre,  knife  or  gunshot  missile.  The  records 
of  military  surgery  contain  numerous  cases  of  deep  incised 
wounds  on  the  back  of  the  neck;  often  frightful  wounds  in  wdiich 
the  subject  was  half  decapitated.  If  the  lesion  does  not  impli- 
cate the  spinal  column  it  is  not  necessarily  fatal.  Such  wound 
has  been  in  flap  form,  and  the  flap,  as  in  the  case  of  Larrey, 
being  pendulous  downwards.  Such  wound  should  be  closed  by 
metallic  suture,  and  the  patient  remain  absolutely  at  rest  in  the 
lying  posture.  In  Larrey's  case,  though  the  patient  recovered,  he 
remained  without  generative  power. 

The  penetrating  blade  may  enter  the  spinal  canal  and  injure 
the  cord.  The  new-born  infant  has  had  its  existence  criminally 
ended  by  a  needle  which  has  been  thrust  between  the  atlas  and 
the  occiput,  or  between  the  atlas  and  axis  into  the  spinal  cord. 
A  bullet  or  other  missile  would  be  equally  sure  to  terminate  life. 

Deep  wounds  on  the  side  and  front  face  of  the  neck  rarely 
fail  to  imperil  .some  structure  of  vital  im[)ortance;  and  should 


W-OrXDS    OF    THE    XECK.  907 

the  common  carotid  artery  or  the  internal  juguhir  be  divided, 
tlie  work  of  deatlr  is  so  speedy  that  the  surgeon's  services  are 
dispensed  with,  Xelaton  has  said  that  it  takes  a  man  four  min- 
utes to  bleed  to  death  from  the  severed  carotid,  and  but  two  min- 
utes for  the  surgeon  to  tie  the  vessel;  if  he  were  on  the  ground 
and  prepared,  the  writer  will  add.  The  writer  recalls  the  case 
of  a  man  in  tlie  Xew^  York  Emigrant  Hospital,  who  bled  to 
death  in  much  less  than  four  minutes  after  cutting  his  throat; 
a  surgeon,  who  was  at  the  side  of  the  suicide  within  a  minute, 
found  him  dying. 

In  the  study  of  these  wounds  it  is  most  convenient  to  start 
from  the  posterior  part  and  proceed  towards  the  median  line. 

Wounds  in  the  outer  or  lateral  part  of  this  region  may  impli- 
cate superiorly  the  upper  part  of  the  sterno-cleido-mastoid  mus- 
cle, some  branch  of  the  superficial  cervical  plexus,  and  the  exter- 
nal jugular  vein;  lower  down,  in  addition  to  these  structures,  the 
formative  trunks  of  the  axillary  plexus,  and  the  subclavian 
artery  and  vein,  and  the  phrenic  nerve  may  be  wounded.  The 
treatment  of  such  deep  wound  should  be  the  reunion  of  the  sev- 
ered muscle  when  the  ends  are  much  separated;  and  an  opened 
vessel  should  be  ligated;  and  such  ligation  becomes  most  efficient 
when  the  vessel  is  tied  on  each  side  of  the  wound,  and  then 
severed  between. 

Above  the  hyoid  bone  lies  a  space  bounded  superiorly  by  the 
inferior  maxilla,  which  is  rarely  the  site  of  wounds,  neverthe- 
less a  penetrating  instrument  entering  here  may  wound  veins  of 
some  magnitude:  also  the  facial  and  lingual  artery:  likewise 
the  submaxillary  gland,  the  duct  of  Wharton,  and  the  hypoglos- 
sal nerve.  As  treatment,  wounded  vessels  should  be  tied,  and  if 
the  wound  opening  tlie  duct  of  Wharton  remains  as  a  salivary 
fistula,  the  most  rational  management  is  to  remove  the  source  of 
supply,  viz.,  to  extirpate  the  submaxillary  gland.  This  is  readily 
done  by  a  cut  two  inclies  long  parallel  witli  the  margin  of  the 
maxilla  and  midway  between  this  margin  and  the  hyoid  bone. 
Through  this  cut  the  gland  is  reached,  and  the  facial  artery, 
wljich  is  imbedded  in  or  on  the  gland,  is  to  be  ligated  doubly  and 
divided  intermediately:  then  the  gland  is  readily  enucleated 
from  its  niche;  and  when  this  is  done  it  will  be  found  suspended 
to  the  gustatory  nerve  above,  and  to  its  excretory  outlet  in  front; 
these  being  sundered,  the  work  of  extirpation  is  done.  This 
extirpation  of  the  submaxillary  gland  has  been  practiced  by  the 
writer  eight  times  in  the  removal  of  epithelioma  of  the  tongue 


908  WOUNDS    OF    TIIK    NKCK. 

or  iVuni  the  lloor  of  the  luoutli;  and  it  was  so  easih'  done,  and 
tlie  wound  liealed  so  (juickly,  tliat  though  the  procedure  may 
appear  soniewliat  radical,  yet  lie  advises  it  as  the  proper  treat- 
ment of  an  unclosing  fistula  in  the  duct  of  Wharton.  It  is 
probable  that  if  the  hypoglossal  or  gustatory  nerve  were  severed, 
continuity  miglit  be  restored  by  a  suture  of  the  two  ends  of 
the  nerve. 

The  suicidal  knife  sometimes  enters  this  region,  and  may 
accomplish  its  fatal  purpose;  yet,  as  a  rule,  such  wound  fails  of 
its  intent.  The  treatment  of  this  wound  will  be  considered 
hereafter. 

A\'ithin  the  triangular  space  having  its  ba.se  at  the  hyoid 
bone,  and  bounded  laterally  by  the  sterno-cleido-mastoid  nms- 
cles,  lie  the  laryngo-tracheal  canal,  the  oesophagus,  and  the  large 
cervical  vessels  and  respiratory  nerves.  A  wound  of  any  of 
these,  if  it  does  not  destroy,  will  at  least  imperil  life. 

The  median  air-canal  is  often  opened;  of  thirty-one  wounds 
of  the  ileck  seen  by  DiefFenbach,  of  which  lifteen  ended  fatally, 
two  implicated  this  channel.  Horteloup  has  collected  one  hun- 
dred cases  of  such  wound. 

The  suicide  and  homicide  have  furnished  many  examples  of 
this  lesion,  in  which  the  wounds  passed  from  without  inwards; 
and,  reversely,  violent  expiratory  effort  has  wounded  the  trachea 
from  within  outwards,  leading  to  emphysematous  diffusion  of  air 
into  the  tissues  of  the  neck.  Wounds  penetrating  the  air-canal 
may  be  caused  by  an  infinite  variety  of  instruments;  in  fact,^ 
they  can  arise  from  any  sharp-pointed  instrument  or  object,  from] 
a  needle  to  the  wooden  staff  of  a  rocket;  an  example  of  the  lat- 
ter was  seen  by  the  author. 

Of  wounds  which  implicate  the  tracheo-laryngeal  canal,  the 
figures  of  Durham  and  Plorteloup  show  that  the  upper  portion 
is  less  often  wounded  than  the  lower  part;  the  former  found  that 
of  one  hundred  and  fifty-eight  cases  fifty-six,  or  about  one-third, 
were  situated  above  the  thyroid  cartilage;  and  these  figures  do 
not  differ  much  from  those  of  Horteloup. 

The  direction  of  the  wound  is  usually  oblique  or  transverse, 
3'et  such  wounds  in  longitudinal  direction  have  often  arisen  from 
the  surgeon's  knife.  The  wound  may  be  a  single  one  or  it  may 
be  multiple;  the  maniacal  inspiration  of  the  suicide  has  fur- 
nkshed  frightful  examples  of  the  multiple  form;  his  instrument, 
frec[uently  dull  or  unsuited  to  such  work,  seeks,  often  in  vain,  to 
penetrate  the  larynx,  which  offers  a  {)rotective  barrier  to  vessels 


WOUNDS    OF    THE    NECK.  909 

which  lie  at  its  sides.  And  this  security  is  increased  by  the 
ossific  change  which,  in  the  old  subject,  occurs  in  the  larynx  and 
trachea.  In  his  maddened  fury  to  effect  his  destruction,  the 
desperate  subject  has  been  known  to  wound  his  thyroid  cartilage 
at  several  points,  and  sometimes  he  has  detached  a  large  part  of 
the  larynx.  Of  the  ferocity  with  which,  sometimes,  such  self- 
inflicted  wounds  are  made  is  the  case  narrated  by  Jameson :  a 
woman  who  had  cut  her  throat  and  was  unable  to  speak,  drew 
from  her  jDocket  the  cricoid,  the  arytenoid  cartilages,  a  portion 
of  the  thyroid  cartilage,  and  a  tracheal  ring,  which  she  had  cut 
out.  This  woman  lived  thirty-four  hours,  and  had  she  been 
found  dead,  her  death  would  certainly  have  been  attributed  to 
violence  perpetrated  by  an  assassin's  hand. 

That  such  violence  can  be  inflicted  by  the  subject  himself 
seems  incredible,  and  it  could  not  be  done  were  it  not  that  in  his 
frenzy  he  becomes  insensible  to  pain.  This  fact  the  writer  has 
verified  by  statements  of  those  who  have  attempted  self- 
destruction  :  in  one  case  a  w'oman  had  thrust  a  knife,  handle  and 
all,  into  her  chest,  and  yet  she  had  no  recollection  of  any  pain 
from  the  act.  And  this  statement  has  been  corroborated  by 
others  who  failed  in  their  suicidal  attempts. 

The  wound  implicating  the  laryngo-tracheal  canal,  owing  to 
the  complexity  of  structure,  presents  a  variety  of  conditions,  and 
these,  according  to  their  time  of  appearance,  may  be  immediate, 
recent  or  late. 

As  immediate  results  which  may  arise  are  emphysema,  bleed- 
ing, which  may  cause  syncope  and  asphyxia,  and  gaping  of  the 
divided  tissues;  and,  as  respiratory  trouble,  there  may  be  suffo- 
cation, and  disturbance  of  or  loss  of  voice.  As  subsequent  mor- 
bid development  there  may  be  swelling  and  cedema  of  the 
mucous  membrane,  supjDuration,  and  inflammation  of  the  air- 
canal,  and  this  may  reach  into  the  lungs.  As  phenomena  which 
can  arise  still  later,  are  narrowing  of  the  canal,  disturbance  of 
phonation,  cicatricial  retraction,  and  consequent  displacement  of 
parts;  and  in  case  of  non-closure  a  fistulous  orifice  may  remain. 

In  case  the  wound  is  a  large  free  opening  of  the  air-channel, 
the  air  is  inspired  and  expired  through  the  wound;  but  if  the 
wound  consist  of  a  narrow  fistulous  canal,  then  the  patient  will 
breathe  in  the  air  through  the  mouth  or  nose,  but  will  expire  it 
partly  through  the  narrow  wound  ;  and  as  the  exit  through  the 
latter  is  not  free,  the  escaping  air  may  enter  the  subcutaneous 
tissue  and  produce  a  puffy  swelling  around  the  wound;  and  this 


910  worxDs  OF  THE  neck. 

iiitravasation  of  air  sometimes  occurs  on  an  enormous  scale. 
In  a  case  seen  by  Pard  the  emphysematous  diffusion  extended 
from  the  neck  to  the  bod}-,  the  entire  surface  of  which  became 
swollen.  The  air,  instead  of  entering  the  subcutaneous  tissues, 
has  penetrated  underneath  the  mucous  membrane  and  lessened 
the  calibre  of  the  canal,  and^  if  this  should  encroach  on  the  glottis, 
the  patient  may  be  asphyxiated.  In  the  operation  of  trache- 
otomy subcutaneous  emphysema  has  been  seen;  such  accident  is 
referable  to  inexpertness  in  doing  the  work. 

If  vessels  are  opened  near  the  tracheal  or  laryngeal  wound, 
the  escaping  blood  ma}''  be  aspirated  into  the  air-passages  and 
cause aspliA'xia;  such  unfortunate  accident,  as  the  writer's  expe- 
rience can  authenticate,  has  brought  to  a  sudden  halt  the  work 
of  the  tracheotomy,  for  the  clotted  blood  lodged  in  the  bronchial 
branches  can  obstruct  aeration  as  effectually  as  can  the  crou[)al 
pseudoplasm  fixed  in  the  trachea  or  lar3'nx  above.  And  sucli 
blood  may  arise  not  only  from  lesion  of  vessels  outside  of  the 
canal,  but  a  wound  of  the  congested  mucous  membrane,  accord- 
ing to  Gueterbock,  has  yielded  blood  which  asphyxiated  a  feeble 
subject. 

In  the  improper  closure  of  a  wound  which  has  opened  the 
larynx  or  trachea,  by  which  gaping  vessels  were  concealed,  l)lood 
has  laterally  entered  the  air-tube,  and  entering  the  lungs,  it  has 
maintained,  for  a  time,  a  harassing  cough  :  and  this  in  its  turn 
favored  the  bleeding. 

If  the  amount  of  blood  lost  be  considerable,  it  may  induce 
syncope,  and  this  syncopal  state  has  lasted  so  long  in  some  cases 
as  to  simulate  the  moribund  condition.  Horteloup  records  cases 
in  which  this  condition  lasted  eight  or  ten  hour.s. 

The  gaping  of  the  wound  may  be  great;  for  example,  if  it  lie 
transversely,  the  divided  muscles  retract  greatly,  but  if  the  wound 
pass  irregularly  from  its  outer  to  its  inner  ending,  then  it  s{)onta- 
neously  closes,  valve-like,  especially  in  the  inspirator}^  act.  A 
transverse  wound  in  the  thyrohyoidean  space,  or  the  cricothy- 
roidean  membrane,  may  leave  a  widely  gaping  breach  in  the 
air-tube.  If  it  is  yet  lower,  the  trachea  may  be  wholly  divided, 
and  a  considerable  interval  be  left  between  the  ends.  Through 
such  widely  gaping  wound  the  patient  breathes,  and,  in  cough- 
ing, mucus  and  pulmonary  excreta  are  expelled  through  it. 

The  wound  opening  into  the  air-tube,  if  below  the  glottis, 
influences  the  voice;  if  it  be  large,  complete  aphonia  results;  but 
if  the  wound  be  small,  the  voice  may  be  changed  in  tone  and 


WOUNDS    OF    THE    NECK.  911 

strength.  The  large  gaping  wound  which  annuls  phonation  is 
taken  advantage  of  by  the  vivisectionist  to  enforce  the  silence  of 
his  victim. 

Injuries  of  the  larynx,  if  severe,  as  a  rule,  annul  or  destroy 
the  voice;  yet  there  are  reports  of  cases  in  which  the  voice  still 
remained,  although  the  larynx  had  been  opened  near  the  vocal 
cords.  In  such  cases,  which  are  at  variance  with  the  accepted 
facts  of  physiology,  perhaps,  the  superior  thyro-arytenoid  liga- 
ments vicariously  represent  the  normal  chords. 

In  these  laryngo-tracheal  wounds,  if  the  inferior  laryngeal 
nerves  be  intact,  then  a  closure  of  the  wound  will  enable  the 
patient  to  speak  aloud.  And  in  legal  medicine  this  fact  has  been 
utilized;  the  wound  has  been  temporarily  closed  to  permit  the 
subject  to  speak  the  name  of  him  who  has  wounded  him:  and 
with  the  object  of  restoring  phonation,  Pare  was  accustomed  to 
close  such  wounds. 

Wounds  of  the  air-passage  can,  soon  after  their  receipt,  awaken 
an  inflammation  and  oedema  of  the  mucous  membrane,  which, 
besides  obstructing  the  respiration,  may  cause  extensive  suppura- 
tion, from  which  the  pus,  entering  the  air-channel,  may  descend 
into  the  lungs  and  cause  a  low  form  of  pneumonia.  In  addition 
to  the  pneumonic  trouble,  the  pus  may  descend  on  the  outside  of 
the  trachea  and  enter  the  thorax;  such  gravitating  material  may, 
fortunately,  be  arrested  b}^  the  sternum  and  clavicle;  in  fact,  from 
the  writer's  observation,  the  anterior  and  lateral  spaces  are  so 
well  closed  by  their  attachment  to  the  sternum  and  clavicle,  that 
pus  descending  will  rarely  pass  beyond  these  barriers;  however, 
downward  escape  of  pus,  along  the  nerves  forming  the  axillar}'- 
plexus,  into  the  axilla  has  occasionally  been  observed.  Bat  pus, 
which  enters  the  air-tube,  or  oedema  developing  there,  may 
descend  and  awaken  disease  in  the  lungs;  thus  fatal  pneumonic 
disease  has  not  uufrequently  arisen.  And  to  avert  such  ill  action, 
an  external  exit  should  be  prepared  for  all  pus,  or  pus-like  excreta; 
and  the  position  of  the  patient  should  be  such  that  gravitation 
will  become  an  ally,  and  not  an  opponent  of  the  surgeon,  which 
it  often  does  become,  through  his  inattention  to  a  familiar  physi- 
cal law. 

Besides  the  primary  and  early  secondary  results  of  wounds  of 
the  larynx  and  trachea,  there  is  a  third  class,  which  may  be 
denominated,  from  their  time  of  appearance,  remotely  secondary 
events:  such  are  cicatricial  contractions,  displacement  of  parts, 
and  fistulous  openings:  also  vocal  and  respiratory  disturbances 


912  WOUNDS   OF    THE    NECK. 

thence  arise.  Cicatricial  shrinking  of  the  structures  which  have 
been  wounded  may,  according  to  site,  lessen  the  laryngeal  or 
tracheal  canal.  Thus  the  air-tube  may  be  so  narrowed,  tliat  it 
barely  permits  the  passage  of  air  sufficient  for  respiration;  and  in 
such  cases,  tlie  breathing  is  labored,  and  for  its  accomi)lishment 
some  voluntary  effort  is  necessary.  Such  patients  are  trammeled 
in  their  movements,  since  they  can  only  indulge  in  active  exercise 
at  the  cost  of  labored  respiration,  or  even  of  painful  dyspn(]ea. 

The  condition  of  the  healed  parts  may  be  such  that  in  expira- 
tion the  tube  is  nearly  of  normal  calibre,  yet  during  inspiration 
the  covering  of  the  opening  is  drawn  inwards,  and  so  narrows 
the  passage  that  breathing  is  hampered.  And  when  the  respira- 
tion is  excited  from  any  cause,  this  indrawing  of  the  cicatrized 
breach  is  so  great  as  to  painfully  impede  the  breathing.  Again, 
there  may  be  a  valve-like  formation  which  develops  within  the 
air-canal,  in  the  healing  of  a  wound,  and  which,  in  the  inspira- 
tory or  the  expiratory  movement,  is  uplifted,  and  partly  occludes 
the  canal.  Both  of  these  cases,  in  which  the  passage  is  alternately 
narrowed  and  then  reopened,  have  been  observed  as  the  result  of 
tracheotomy  performed  by  the  writer;  such  occlusive  result, 
fortunately,  rarely  follows  this  operation;  yet  in  a  series  of  fifty 
tracheotomies  done  by  the  writer,  it  occurred  twice,  and  remained 
as  a  troublesome  result  of  the  operation. 

Such  tracheo-laryngeal  wound  may  not  close,  but  leave  a 
fistulous  orifice;  and  this  fistula,  according  to  its  position  and 
size,  will  influence  the  voice.  If  the  opening  be  underneath  the 
vocal  chords  and  be  large,  the  voice  will  be  obliterated,  or  reduced 
in  tone  and  force;  but  if  the  opening  be  above  the  glottis,  then 
the  voice  may  also  be  weakened,  and  whatever  may  be  the  site  of 
the  opening,  the  voice  will  be  altered  in  its  character;  and  its 
tone  may  be  pij)ing,  sibilant,  harsh  and  unnatural.  If  the 
wound  be  laryngeal  and  near  the  glottis,  in  healing,  w'hether  the 
wound  remains  open  or  closes,  the  vocal  chords  may  be  forced 
into  various  mal-positions;  and  the  cicatricial  contraction  in  such 
wound  may  render  the  chords  convergent  or  divergent,  thus  caus- 
ing the  glottis  to  be  abnormally  narrow  or  unusually  wide;  and, 
again,  the  triangular  form  of  the  opening  may  be  converted  into 
a  rounded  or  other  irregular  outline.  And  such  variety  of  out- 
line must  furnish  equal  diversity  of  phonation. 

Alteration,  or  a  loss  of  voice,  can  arise  from  lesion  of  the 
inferior  laryngeal  nerve;  and  if  this  lesion  be  only  unilateral, 
the  voice  will  be  nearly  altered  to  a  falsetto  tone;  this  the  writer 


WOUNDS    OF    THE    NECK.  913 

has  observed  in  two  cases  of  unilateral  recurrent  lesion.  In  one 
case,  the  vagus,  in  the  removal  of  a  growth  on  the  neck,  was 
severed  above  the  origin  of  the  inferior  lar3aigeal  nerve,  and  the 
voice  was  reduced  to  a  creaking  falsetto;  and,  in  a  second  case, 
the  nerve  was  injured  but  not  destroyed  on  one  side,  in  the 
removal  of  a  goitrous  tumor;  in  this  case  a  falsetto  phonation 
resulted,  which  continued  for  a  number  of  months;  yet  finally, 
the  voice  was  restored  to  normal  character. 

In  these  injuries  of  the  laryngeal  vocal  apparatus,  writers 
have  reported  cases  in  which  the  patient  could  not  pronounce 
correctly  certain  letters;  it  is  probable  that  such  irregularity  was 
dependent  on  some  defect  of  the  organs  of  articulation,  rather 
than  of  the  larynx  or  trachea. 

Remote  trouble  from  wounds  involving  the  air-passages  may 
arise  from  adhesions,  which  interfere  with  the  ascent  and  descent 
of  these  parts  in  deglutition;  also,  such  cicatricial  adherence  may 
interfere  with  motions  which  normally  occur  in  the  use  of  the 
voice. 

In  case  an  opening  remains  in  the  air-passage  in  the  male 
who  has  an  abundant  hirsute  investment  of  the  parts,  the  hair 
may  grow  inwards  from  the  inverted  derm,  and  obstruct  the 
canal.  Thus  in  a  case  seen  by  the  writer,  in  which  there  remained 
an  opening  into  the  larynx,  the  hair  penetrated  the  air-passage, 
and  almost  suffocated  the  patient.  This  occurred  at  sea,  the 
man  being  a  sailor,  and  but  for  his  presence  of  mind  in  tearing 
open  the  wound  when  he  was  nearly  suffocated,  he  would  have 
died.  At  a  later  time  when  a  similar  accident  seemed  impend- 
ing, the  patient  consulted  the  writer,  who  performed  an  operation 
on  him  for  the  permanent  closure  of  the  wound. 

Along  with  the  lesion  of  the  larynx  or  trachea,  the  oesopha- 
gus may  also  be  wounded.  In  the  suicidal  attempt  to  cut  the 
throat,  if  the  wound  be  high  on  the  neck,  it  may  penetrate  the 
pharynx;  also,  in  the  wound  which  is  lower,  in  which  the  tra- 
chea is  wounded,  occasionally  the  adjacent  oesophagus  shares 
in  the  injury.  At  whatever  point  the  oesophagus  be  wounded,  it 
would  be  indicated  by  the  escape  of  mucus  from  the  wound. 
Also,  should  the  patient  swallow  a  fluid,  especially  a  colored  one, 
as  milk,  this  would  escape  from  the  wound,  and  be  evidence  that 
the  gullet  had  been  opened.  Again,  the  oesophagus  alone  may  be 
wounded ;  and  this  lesion  may  be  from  the  inside,  or  from  the 
outside.  On  the  inside,  wounds  can  arise  from  some  sharp  object 
which  has  been  swallowed;  it  may  be  surgical,  as  in  internal 


Ul-l  WOUNDS    OF    THE    NECK. 

(esopbagotoniy.  And  wounds  from  the  outside  ma}'  be  from 
external  re.so[)liagotoniy,  or  from  some  accidental  cause.  Such 
wounds,  wiien  longitudinal,  gap  less  than  when  they  lie  trans- 
versely: and  the  former  are  more  readily  healed. 

The  simultaneous  opening  of  the  cesopliagus  along  with  the 
air-passage  is  more  frequent  than  an  isolated  wound  of  the 
former.  And  the  wound,  according  to  Horteloup,  is  usually  of 
large  dimensions.  Such  large  wound  has,  as  sym})toms,  the  con- 
stant escape  of  mucus,  the  exit  of  food  which  is  swallowed,  and 
retraction  of  the  lips  of  the  wound;  and  even  when  the  section 
of  the  tube  is  incom})lete,  tlie  lower  end  is  retracted. 

Small  penetrating  wounds  are  less  dangerous;  still,  in  the 
case  observed  by  Craveilhier,  in  wliich  tlie  small  blade  of  a. knife 
pierced  the  oesophagus  al)Ove  the  sternum,  the  patient  died. 

The  oesophagus, though  so  narrow  in  calibre,  may  be  wounded 
by  the  gunshot  missile;  and  such  wounds  often  leave  a  fistulous 
opening;  or,  should  tliey  close,  tlie  canal  remains  in  a  narrowed 
condition. 

Besides  the  alimentary  and  air-passages  which  are  contained 
in  the  inner  cervical  triangle,  there  are  situated  there  the  great 
vessels,  which  being  wounded,  the  patient's  life  is  at  once  lost  or 
greatly  imperiled.  The  simultaneous  severing  of  the  primitive 
carotids,  done  with  suicidal  |)urj)ose,  quickly  destroyed  life  in  a 
case  before  mentioned,  which  occurred  within  the  author's  o])ser- 
vation. 

As  vessels  which  may  be  opened  here,  are  the  carotid  artery, 
internal  jugular  vein,  the  thyroid  and  vertebral  arteries,  and  their 
attendant  veins.  The  innominate  artery  rising  abnormally  high, 
as  it  does  sometimes,  would  be  endangered  by  a  wound  in  the 
lower  part  of  the  right  side  of  the  neck.  A  penetrating  Avound 
may  implicate  a  single  one  of  the  cervical  vesisels;  and  the 
diagnostic  determination  of  the  one  injured  is  often  a  difficult 
problem  to  solve.  For  example,  when  the  vertebral  is  wounded, 
the  surgeon  is  puzzled  to  decide  whether  the  resulting  htemorrhage 
may  be  from  the  middle  or  inferior  thyroid,  carotid  or  vertebral 
artery:  especially,  where  the  wound  wliich  reached  the  vessel 
was  a  narrow  one,  and  traversed  the  overlying  structures, 
obliquely. 

Besides  the  danger  of  bleeding  from  a  wound  of  the  carotid 
artery  or  internal  jugular  vein,  the  patient's  life  is  sometimes 
imperiled  by  the  means  which  are  employed  to  arrest  the  bleed- 
ing.    The  ligation  of  the  carotid  artery  has  interfered  with  the 


WOUXDS    OF    THE    NECK.  915 

nutrition  of  the  brain,  and,  as  result,  the  patient  has  remained 
crippled  in  motor  power,  sensation  and  intellect.  As  excep- 
tional accident,  the  ligation  of  a  wounded  internal  jugular  vein 
has  led  to  a  thrombus  which  reached  into  the  venous  sinuses  of 
the  lesion,  and  caused  irreparable  mischief  there.  The  aspira- 
tion of  air  into  such  venous  wound  has  already  been  considered. 
In  forensic  medical  inquiry  the  Cjuestion  ma}'-  arise,  whether 
the  wound  on  the  neck  was  self-inflicted  or  was  the  work  of  an 
assassin's  hand.  In  1868  Achille  Juhel  announced  the  followino- 
as  the  result  of  his  study  of  this  matter:  the  assassin's  cut  pro- 
ceeds from  the  patient's  right  toward  the  left  side;  the  cut  passes 
from  below  upwards,  and  from  before,  backwards.  The  wound 
is  deepest  in  front  where  the  knife  first  entered.  The  suicide's 
cut  lies  nearly  horizontal,  and  is  more  on  the  left  side,  running 
towards  the  right.  The  assassin,  as  a  rule,  severs  more  muscles 
and  vessels  than  does  the  saicide. 

The  prognostic  augury  of  wounds  of  the  neck  is  often  a 
sinister  one.  The  opinion  of  DiefFenbach,  and  which  other  sur- 
gical writers  generally  acce^^t,  is  formulated  as  follows:  Simple 
wounds  of  the  neck  which  are  limited  to  the  cutaneous  structures 
rarely  heal  by  first  intention.  And  when  the  wound  is  deep, 
even  though  it  does  not  enter  the  air-passages,  it  may  cause 
death  by  suppuration  within  the  cellular  tissue,  and  by  deep 
burrowing  of  pus.  The  dangers  here  referred  to  are  less  since 
the  advent  of  the  antiseptic  treatment  of  wounds. 

Treatment. — The  treatment  will  vary  according  as  the  wound 
is  superficial  or  deep,  and,  when  deep,  according  to  the  parts 
which  are  injured. 

The  superficial  wound,  if  its  edges  are  smooth,  should  be 
closed  by  suture;  but  if  the  margins  are  lacerated  or  irregular, 
they  should  be  trimmed,  and  then  united  by  proper  sutures. 
Such  closed  wound  may  be  dressed  with  the  compound  tincture 
of  benzoin,  and  covered  with  isinglass  plaster.  In  this  way,  the 
writer  has  often  obtained  union  by  first  intention  ;  yet  this  fortu- 
nate termination  is  not  alwa^'s  arrived  at:  the  w^ounded  parts 
may  suppurate,  and  healing  be  prolonged.  From  the  writer's 
experience,  suppurative  action  is  less  frequent  if  such  wound  be 
dressed  after  sutural  closure  with  lint  retained  moist  with  a  dilute 
alcoholic  solution.  To  promote  healing,  all  movements,  as 
flexion  and  extension  of  the  neck,  should  be  guarded  against,  as 
much  as  possible,  by  some  contentive  appliance. 

If  the  wound  be  deep  and  situate^  in  tlie  anterior  region  of 


91()  WOUNDS    OF    THK    NECK. 

tlie  neck,  and  involves,  as  it  often  does,  the  vessels  and  the  air- 
passage,  then,  as  immediate  cojisequences,  are  gaping  of  the 
wound,  bleeding  from  the  opened  veins  and  arteries,  ])ossible 
aspiration  of  air  into  the  veins,  and  impending  asphyxia  from 
the  flowing  or  suction  of  blood  into  the  air-passages.  To  fore- 
stall the  fatal  termination  to  which  these  accidents  tend,  })rompt 
thought  and  speedy  action  are  demanded:  action  free  from  error, 
since  a  mistake  there  made  can  only  be  corrected  in  the  next 
opportunity. 

If  vessels  are  opened,  the  first  thing  to  be  done  should  be  to 
com])rcss  the  wound  with  one  hand  so  as  to  check  the  bleeding; 
and  then  with  tlie  other  hand  make  pressure  on  the  cardiac  side,  so 
as  to  control  tlie  arterial  bleeding;  or  this  comjjression  can  be 
done  bv  an  assistant  who  may  press  with  one  hand  on  tiie  central 
side,  and  with  the  other,  on  the  peripheral  side  of  the  wound. 
Compression  thus  done,  will  control  both  arterial  and  venous 
bleeding,  and  will  prevent  asjtiration  of  air;  and  the  bleeding 
being  thus,  for  the  moment,  controlled,  the  vessels  must  be  sought 
for  and  caught  with  clasp  forceps,  an.d  then,  one  by  one,  carefully 
tied.  And  if  there  be  refluent  blood  from  the  untied  end,  tliis 
end  must  likewise  be  tied. 

Should  the  tliyroidean  structure  be  wounded  along  with  the 
air-passage  and  there  is  general  bleeding,  as  from  a  wet  sponge 
which  is  squeezed,  then  the  peril  of  asphyxia  deserves  the  first 
care;  and  the  best  means  to  avert  this  is  to  quickly  turn  the 
patient  so  that  the  blood  will  flow  outwards  rather  than  inwards; 
and  as  soon  as  possible,  introduce  a  tracheal  canula  into  the  o[)en- 
ing  in  the  air-passage;  such  canula  should  be  large  enough  to 
fully  occupy  the  tracheal  calibre.  If  the  wound  be  of  such  char- 
acter or  shape  that  it  is  unsuited  for  the  admission  of  the  canula, 
then  an  opening  may  be  made  lower  down.  And  thus  provision 
being  made  for  respiration,  the  surgeon  can  search  for  the  open 
vessels  and  tie  them;  and  in  the  case  of  parenchymatous  haemor- 
rhage, in  which  the  vessels  are  indistinguishable,  then  circum- 
scriptive ligation  in  mass  may  be  practiced. 

In  the  event  that  the  patient  is  asphyxiated  or  drowned  from 
his  own  blood,  then  the  practice  has  been  resorted  to  of  with- 
drawing this  blood  by  suction:  a  plan  akin  to  that  of  Hueter. 
by  which  he  extracted  bronchial  excreta.  This  procedure  of 
suction  was  also  advised  by  Roux;  but,  though  rational,  it  does 
not  appear  to  have  often  been  resorted  to.  Such  aspiration,  or, 
better  named,  expiration,  may  be  done  by  means  of  a  catheter 


WOUNDS    OF    THE    NECK.  917 

constructed  of  A'ulcanized  rubber,  to  -which  the  suction  end  of  a 
rubber  syringe  is  attached;  or,  instead  of  the  syringe,. a  compress- 
ible elastic  bag  may  be  attached,  and  the  blood  or  other  material 
thus  withdrawn. 

A  fragment  of  cartilage  has  been  detached  and  in.spired  into 
the  air-canal,  and  obstructed  the  breathing;  such  fragment  might 
be  extracted  with  a  long  pair  of  forceps.  Or  the  fragment  might 
be  in  the  shape  of  a  pedunculated  valve;  and  this  valve  during 
inspiration,  could  be  drawn  inwards  so  as  to  obstruct  breathing. 
In  such  a  case,  a  canula  should  be  introduced  througii  the  wound, 
or  underneath  it. 

The  deep  gaping  wound  of  the  air-canal  has  been  the  matter 
of  much  contentious  controversy  among  surgeons.  Shall  such 
wounds  be  left  open,  or  closed  by  suture? 

The  older  surgeons,  chief  among  whom  is  Pare,  completely 
closed  such  wounds  by  suture.  He  treated  three  cases  of  cut- 
throat by  complete  sutural  closure,  and  of  the  number  but  one 
lived;  and  so  little  personal  credit  did  the  pious  surgeon  assume 
to  himself,  that  concerning  his  work,  he  wrote  the  famous  sen- 
tence wdiich  stands  over-the  speaker's  rostrum  in  the  £cole  de 
Medecine,  in  Paris,  "J  treated  him,  but  God  cured  him."  The  old 
Huguenot  showed  a  degree  of  modest  humility  now  seldom 
seen.  The  boastful  manner  in  which  the  surgical  feats  of  to-day 
are  sometimes  heralded  to  the  world,  is  in  ill  accord  with  the 
self-abnegation  of  Ambroise  Pare.  In  more  recent  times  Sabatier 
and  Dieffenbach  have  espoused  the  opposite  plan  of  treatment, 
viz.,  of  non-suture  of  such  wounds,  owing  to  the  difficulty  of  get- 
ting immediate  union.  As  reasons  for  the  difficulty  of  obtaining 
union  after  such  sutural  closure,  Dieffenbach  offers  the  foUowino;: 
the  wound  is  composed  of  tissues  which  are  complex  and  differ 
in  character;  and  there  is  unusual  laxity  of  the  cellular  tissue; 
and,  as  a  result  of  such  conditions,  it  is  diffictilt  to  obtain  com- 
plete coaptation  of  the  edges  of  the  wound,  which  are  often 
infolded:  and  also,  difficult  to  immobilize  the  parts.  Berth erand, 
who  has  studied  these  wounds,  thinks  the  wound  should  be 
suturally  united  when  the  wounded  surfaces  are  smooth  and 
regular;  and  in  such  condition  of  surface,  union  will  be  gotten, 
provided  the  sutures  are  properly  introduced.  If  the  sutures  are 
only  superficially  inserted  in  such  a  case,  there  may  be  failure  of 
complete  union.  If  the  closure  is  merely  superficial,  tlie  wound- 
will  reopen.  To  prevent  this,  the  suttires  'should  be  introduced 
deeply;  such  suture,  including  the  skin,  muscles  and  fascise,  so 


;>18  WOUNDS    OF    THE    NKCK, 

immobilizes  the  parts  that  union  is  not  interfered  with.  The  one 
wounded  face  must  be  brought  accurately  against  the  o})|iosite 
one,  and  the  two  then  sutured  together. 

Such  evenly  wounded  surfaces  rarely  occur;  when  seen,  the 
treatment  of  Bertherand  might  be  safely  j)ursued;  butin  ordinary 
cases,  iu  which  the  surfaces  are  ragged,  lacerated,  or  in  some  way 
irregular,  the  author  advises  that  the  closure  of  the  wound  should 
be  incomplete ;  the  sutures  should  be  introduced  only  at  the  ends 
of  the  gajiing  breach,  while  the  middle,  or  immediate  portion, 
should  remain  open.  Thus  an  outlet  will  remain  through  whicli 
excreta  and  disintegrating  tissue  can  escape  externally ;  for 
should  such  a  wound  be  wholly  closed,  after  the  skin  unites,  as  it 
usually  does,  the  pent-up  excreta  would  pass  into  the  air-canal, 
and  (lesceml  to  the  lungs. 

Gosselin,  Xelaton  and  others,  within  recent  times,  have  prac- 
ticed the  introduction  of  deep  sutures,  in  which  the  breach  in 
the  cartilage  of  the  trachea  or  larynx  is  closed  by  sutures;  and 
this,  from  its  site,  might  be  named  the  cartilaginous  suture.  Tlie 
outer  part  of  the  wound  is  pernntted  to  remain  unclosed,  that  is, 
the  soft  parts  are  left  unsutured.  And-  in  case  the  wound  be  in 
the  h3"othyroidean  membrane,  or  in  the  cricothyroidean  mem- 
brane, deep  closure  may  be  done,  in  which  the  cartilage  is 
pierced  by  the  suture  only  on  one  side.  In  a  case  cited  by  Hor- 
teloup,  the  suture  passed  through  the  upper  border  of  the  thyroid 
cartilage  and  included,  on  the  other  side,  the  hyoid  bone. 

According  to  South,  the  plan  to  be  pursued  must  conform  to 
the  freedom  or  difficulty  of  respiration  which  occurs  when  the 
wound  is  closed;  for,  sometimes,  when  the  wound  is  closed,  the 
patient  finds  it  difficult  to  breathe;  and,  in  such  a  case,  the  plan 
of  non-closure  must  be  pursued,  which  will  permit  a  part  of  the 
inspired  air  to  enter  through  the  wound.  But  if  the  breathing  is 
unimpeded  when  the  union  is  complete,  then  South  would  totally 
close  the  wound. 

Other  surgeons,  rejecting  the  suture  entirely,  have  closed  the 
wound  by  adhesive  strips,  which  may  be  prepared  from  rubber 
adhesive  plaster;  or  isinglass  jjlaster  may  be  used,  which  is  made 
yet  more  adherent,  and  impermeable  to  water,  by  being  covered 
with  collodion.  Though  not  adopting  this  plan,  the  writer  thinks 
it  might  be  made  an  adjuvant  to  the  suture ;  namely,  after  the 
wound,  in  which  the  surfaces  are  uneven,  has  been  partially 
sutured,  the  closure  might  be  completed  by  means  of  the  adhesive 
strips. 


WOUNDS    OF    THE    NECK.  919 

Whether  closure  or  incomplete  closure  of  the  wound  be  done, 
an  important  aid  in  the  treatment  is  to  counteract,  as  far  as  practi- 
cable, the  movements  of  the  head  and  neck.  A  simple  plan  to 
do  this  ,is  to  fasten  a  cap  on  the  head;  and  from  this  straps 
descend,  which  are  to  be  fastened  to  the  shoulders,  and  also  to  a 
circular  band  around  the  waist.  The  same  may  be  done  by 
strips  of  adhesive  plaster,  or  by  a  gypsum  bandage.  The  appli- 
ance of  fixation  by  a  gypsum  bandage,  though  unsightly  and 
heavy,  is  more  trustworth}^  than  the  other  plans  mentioned.  For 
this  purpose,  in  a  manner  similar  to  that  mentioned  in  the 
treatment  of  torticollis,  let  the  head,  except  the  face,  be  covered 
with  a  cap,  and  the  shoulders  and  armpits  be  enveloped  in  cotton 
wadding;  and  about  tlie  parts  thus  protected,  let  the  gypsum- 
covered  bandage  be  carried  and  so  placed  as  to  leave  an  opening 
for  dressing  the  wound;  and  as  this  is  being  done,  the  head  must 
be  so  inclined  that  all  tension  should  be  removed  from  the 
wounded  parts;  and  this  position  must  be  continued  until  the 
hardened  plaster  will  maintain  the  uplifted  head  in  permanent 
fixation. 

As  additional  j^recaution  to  be  observed,  tlie  movements  of 
deglutition  should  be  avoided  as  far  as  possible;  and  this  may 
be  done  by  passing  aliment  in  fluid  form,  through  an  oesophageal 
tube;  and  should  there  be  a  large  wound  in  the  oesophagus,  for 
some  time  the  tube  of  alimentation  may  continue  downwards 
through  the  wounded  portion  to  the  stomach.  If  this  cannot  be 
done  through  the  mouth,  the  food  may  be  carried  through  a  tube 
which  is  introduced  through  the  inferior  meatus  of  the  nose, 
pharynx  and  entire  oesophagus.  Permanent  retention  of  the  tube 
in  place,  rather  than  its  occasional  introduction,  is  advised ;  for, 
in  the  latter  w^ay,  the  healing  wound  may  be  disturbed,  or 
reopened. 

In  the  cicatrization  of  wounds  which  open  into  the  air-canal 
and  oesophagus,  there  is  often  a  tendency  to  strictural  contraction. 
Such  narrowing  may  be  counteracted  by  the  occasional  introduc- 
tion of  a  sound  into  the  air-passage,  or  the  oesophagus.  In  the 
event  of  the  wound  having  healed,  and  stenosis  remains,  the 
latter  may  be  relieved  by  the  plan  of  Dolbeau  and  others,  in 
wdiich  a  narrow-bladed  knife  is  passed  into  the  contracted  canal, 
and  an  incision  made  by  which  dilatation  can  be  done  and  main- 
tained by  means  of  sounds  introduced  daily,  or  once  in  two  days. 
A  recent  authority  of  distinction  in  this  work  is  Schrotter,  wlio 
has  invented  a   series  of   sounds  by    which   narrowing  in  the 


920  WOUNDS    OF    THE    XPXK. 

larynx  can  be  overcome.  As  aid  in  this  work,  the  mucous  mem- 
brane of  the  parts  may  be  rendered  insensible  by  means  of 
cocaine. 

Instead  of  stenosis  the  wounded  oesophagus  may  become  the 
site  of  dilatation  at  or  above  the  site  of  the  lesion;  a  species  of 
diverticulum  is  thus  formed,  which  may  be  relieved  by  excision 
of  a  section  of  the  pouch. 

Emphysematous  infiltration  of  air  in  the  subcutaneous  and 
cellular  tissue  seldom  occurs  to  an  extent  that  demands  attention : 
should  it  do  so,  the  treatment  of  Hennen  may  be  pursued,  viz.,  to 
make  numerous  punctures  into  the  emphysematous  structure, 
and  then  make  compression  .so  as  to  express  the  air  through  the 
openings. 

In  some  wounds  of  the  air-passage  there  may  arise  a  harass- 
iuQ  cough,  cau.sed  bv  inflammatorv  action  within  the  trachea  or 
larynx.  Formerly,  to  combat  this  inflammation,  free  bleeding 
was  resorted  to;  this  treatment  has  pro})erly  beconje  nearly  obso- 
lete, and  if  practiced,  it  should  only  be  done  in  the  very  plethoric 
subject.  If  there  be  such  indication,  the  abstraction  of  blood 
might  be  done  locally  by  leeches.  The  functional  irritation  can 
generally  be  alleviated  by  the  administration  of  opium  or  hyos- 
cyamus.  Should  the  cough  and  spasmodic  movement  of  the 
parts  depend  on  the  retention  of  muco-purulent  matter,  which, 
not  having  exit,  causes  these  troubles,  then  relief  could  scarcely  be 
expected  from  the  means  just  mentioned,  and  the  better  cour.se  is 
to  open  the  Avound,  so  that  tlie.se  materials  may  have  more  direct 
escape.  Later,  when  the  excreta  become  less  viscid  and  less  in 
amount,  the  woun<l  can  be  reclosed. 

Secondary  haemorrhage,  occurring  early,  or  at  a  later  [)eriod 
has  sometimes  supervened,  and  given  much  trouble;  indeed, 
death  has  thus  occurred  in  cases  which  promised  a  recovery;  and 
this  has  happened  in  ca.ses  which  had  been  closed,  as  well  as  in 
those  left  open.  To  guard  against  this,  diligent  search  for,  and 
accurate  ligation  of,  all  vessels  ogened,  should  be  done  at  the 
first  dressing  of  the  wound;  for  such  work  done  after  the  parts 
have  lost  their  natural  features  is  one  of  the  most  difficult  of 
surgical  ta.sks:  so  difficult  indeed,  in  some  cases,  that  the  surgeon 
has  sought  refuge  in  the  dubious  expedient  of  the  tampon.  Only 
in  the  case  of  parenchymatous  bleeding,  in  which  it  is  impossible 
to  secure  the  vessels,  should  one  resort  to  plugging  the  wound. 
Tlie  material  for  such  tampon  may  be  of  lint  or  gauze  moistened 
with  alcohol,  camphor,  or  other  asepticizing  agent.     Sponge  has 


WOUNDS    OF    THE    NECK.  921 

been  used  for  the  same  purpose;  and,  as  a  mechanical  hseraostatic, 
it  is  one  of  the  best  which  can  be  selected. 

In  case  there  remains  a  fistula  into  the  air-canal  or  oesophagus, 
after  the  healing  of  a  wound  which  implicated  these  canals, 
closure  of  the  same  may  be  attempted  by  a  plastic  procedure, 
according  to  one  of  the  following  plans: — 

1.  If  the  fistula  be  small  and  deep,  and  the  parts  adjacent 
easily  movable,  then  closure  may  be  accomplished  by  carefully 
and  thoroughly  excising  the  wall  of  the  fistula,  and  then  closing 
by  one  or  more  deep  metallic  sutures,  which  should  not  be  too 
tightly  closed.  If  no  suppuration  occurs,  the  sutures  should 
remain  in  site  for  a  week,  and,  after  their  removal,  the  closure 
should  be  maintained  by  adhesive  plaster. 

2.  If  the  fistula  be  deep  or  shallow  and  the  inner  portion  be 
surrounded  by  immovable  cartilage,  then  the  tissues  which 
inclose  the  cartilage  must  be  opened  and  dissected  from  the 
cartilage,  and  then  closure  be  made  with  metallic  sutures.  Upon 
the  external  dressing,  some  pressure  should  be  made  so  as  to  force 
the  occluding  soft  parts  into  the  opening,  and  thus  complete  closure 
is  insured. 

3.  Should  closure  not  be  feasible  by  one  of  the  plans  men- 
tioned, then,  after  trimming  the  walls  of  the  fistulous  opening,  a 
pedunculated  flap  may  be  uplifted  from  the  side  where  it  can  be 
best  spared,  and  twisted  and  carried  into  the  opening,,  and 
retained  there  by  sutures. 

4.  Balassa  advised,  as  a  plan  of  closure,  to  form  a  flap,  which, 
when  put  in  position,  will  leave  the  epidermal  surface  turned 
inwards.  An  objection  to  this  plan  is  that  the  flap  would  contain 
hair-bulbs,  whence  liair  developing,  would  be  seriously  out  of 
place,  and  certainly  disturb  respiration. 

In  the  fistula  of  small  calibre,  such  as  is  usually  met  with  as 
tlie  result  of  wounds  opening  the  larynx  or  trachea,  closure  is 
commonly  practicable  by  the  first  method;  but  should  there  be 
some  loss  of  cartilaginous  structure  resulting  in  a  larger  opening 
of  the  air-canal,  then  it  would  be  necessary  to  employ  the  third 
method ;  and  then,  if  the  breach  were  a  large  one,  some  broncho- 
plastic,  or  rather  chondroplastic,  procedure  would  be  required; 
for  if  merely  a  bridge  of  soft  parts  were  stretched  across  the 
breach,  then  such  movable  operculum  would  sink  during  inspira- 
tion and  interfere  with  breathing.  To  obviate  this,  the  expedi- 
ent might  be  resorted  to  of  shifting  a  small  section  of  the  carti- 
laginous wall  so  as  to  support  and  give  fixity  to  the  replacing 
59 


022  WOUNDS    OF    THE    NECK. 

bridge.     Such  sustaining   arcli  might  be  devised  by  shifting   a 
part  or  whole  of  a  tracheal  ring. 

Roux,  to  close  sucli  fistulio,  dissects  off  the  lining  membrane 
and  thrusts  this  inwards;  then  he  closes  the  outer  opening  with 
deep  sutures.  He  next  forms  a  canal  near  by,  of  which  the 
inner  end  lies  in  the  inner  part  of  the  fistula;  thus  proceeding, 
the  outer  part  of  the  old  fistula  is  closed,  after  which  the  new 
one  will  close  spontaneously. 

Wounds  of  the  air-passages  in  which  there  is  no  breach  of 
the  derm  will  now  be  considered;  this  list  contains  fracture  of 
the  hyoid  bone  and  of  the  thyroid  and  cricoid  cartilages,  and, 
finally,  hanging. 

Fracture  of  tlie  Hyoid  Bone. — The  os  hyoides  may  be  broken  by 
external  violence  acting  directly;  it  may  also  occur  from  mus- 
cular action. 

The  fracture  is  usually  limited  to  one  or  more  of  the  cornua. 
As  exceptions  to  this  are  the  gunshot  wounds,  from  which  the 
bone  may  be  broken  in  any  part  of  its  body  or  processes. 

South  states  that  he  had  only  observed  this  fracture  in  per- 
sons who  had  been  executed  by  hanging.  Casper,  whose  official 
duty  it  was  to  examine  the  dead  bodies  of  those  who  had  died 
by  hanging  (of  suicidal  subjects  as  well  as  of  those  who  had 
been  executed),  says  that  in  no  case  did  he  find  the  hyoid  bone 
broken.  And  Mackniurdo,  who  was  surgeon  to  the  famous  New- 
gate prison  in  London,  in  wliich  occurred  numerous  executions, 
found  the  hyoid  bone  broken  in  but  one  case. 

In  the  hanging  of  Wirz,  executed  in  1868,  for  his  inhumnn 
treatment  of  Union  prisoners,  the  executioner,  in  his  work,  out- 
did that  done  at  Newgate,  viz.,  the  bone  was  broken  at  six 
points:  whether  by  accident  or  otherwise  is  best  known  to  the 
hangman.  A  strong  hand  grasping  the  upper  part  of  the  neck 
in  front  can  fracture  the  hyoid  bone,  and  this  may  be  verified  by 
experimentations  on  the  cadaver.  It  has  been  seen  by  Mur- 
chison,  Dieff'enbach,  and  others,  as  the  result  of  criminal  attempt 
at  strangling.  Harley  and  Wood  saw  the  bone  broken  from 
falls,  in  which  the  point  of  impact  of  violence  was  on  the  bone. 
And,  as  a  rare  occurrence,  the  bone  has  been  broken  from  mus- 
cular action,  in  which,  the  subject  falling  backw^ards,  there 
occurred  such  violent  contractions  of  the  muscles  of  hj^oidean 
attachment  as  to  break  the  bone. 

This  fracture  is  followed  by  interference  with  the  .several 
movements  or  actions  in  which  the  bone  is  directlv  or  indirectlv 


FRACTURE  OF  THE  LARYNX.  923 

concerned:  thus  there  is  trouble  in  speaking,  swallowing,  and 
other  movements  of  the  tongue.  There  is  swelling,  which  may 
reach  into  the  larynx  and  cause  labored  breathing.  If  the  frag- 
ments are  in  contact,  pressure  over  them  elicits  crepitation;  and 
usually  there  is  deviation  from  the  normal  form  of  the  bone;  and, 
if  the  violence  has  been  great,  a  fragment  may  be  driven  through 
the  pharyngeal  mucous  membrane,  and  bleeding  result.  In 
one  case  reported  a  fragment  was  driven  between  the  epiglottis 
and  the  glottis,  and  caused  death. 

Treatment. — Recovery  with  perfect  restoration  to  form  is 
scarcely  to  be  hoped  for,  since  some  of  tlie  indispensable  func- 
tions of  the  phar3aix  will  necessitate  occasional  movements 
which  will  disturb  the  coaptated  fragments. 

Nevertheless,  restitution  to  normal  form  must  be  attempted 
by  external  and  internal  manipulation.  Should  the  broken 
ends  tend  to  jut  outwards,  correction  may  be  made  by  a  small 
compress  held  in  place  by  adhesive  strips;  and  should  the  ends 
fall  inwards,  as  suggestion  for  trial,  this  compression  may  be 
made  near  the  end  of  the  great  cornu.  Should  the  displaced 
ends  defy  simpler  means  of  rectification,  then  tracheotomy 
being  premised,  the  throat  may  be  plugged  with  lint,  and  pres- 
sure on  the  outside  be  maintained  by  compresses  fixed  by 
adhesive  plaster;  and,  meantime,  liquid  food  may  be  given 
through  an  oesophageal  tube,  which  has  been  introduced  through 
the  inferior  nasal  meatus.  Most  cases,  however,  may  be  treated 
in  a  very  simple  way,  viz.,  to  restore  the  broken  parts  to  normal 
site,  nourish  with  liquid  food,  which  may  be  swallowed  or  con- 
ducted through  a  tube,  with  injunction  to  maintain  the  parts  at 
rest  as  nearly  as  possible. 

Fracture  of  the  Larynx. — The  larynx,  from  its  more  exposed 
position,  is  oftener  fractured  than  the  hyoid  bone,  and  the 
causal  agency  may  be  any  kind  of  outward  violence  acting  on 
the  part,  viz.,  hanging,  great  compression,  a  blow,  and  falling 
against  a  hard  object.  Casper  never  saw  the  larynx  broken 
by  hanging;  still  cases  thus  arising  have  been  reported.  Mor- 
gagni,  an  accurate  observer,  saw  such  fracture  from  hanging. 
To  decide  this  matter,  experimentally,  Haumeder  suspended,  as 
in  the  act  of  hanging,  twenty-six  cadavers,  with  the  following 
result:  the  hyoid  bone  was  broken  in  twelve  cases.  The  cornua 
of  the  thyroid  cartilage  were  fractured  in  but  six  cases;  and  in 
one  single  case,  in  which  the  cord  was  placed  beneath  the  thy- 
roid cartilage,  the  cricoid  cartilage  was  broken. 


924  WOUNDS    OF    THE    NKCK. 

Ccivasse  has  likewise  done  some  experimental  work  in  this 
field;  he  found  that  from  a  blow  on  the  front  of  the  laiynx 
there  can  be  produced  a  median  fractnre  or  a  lateral  one;  and  he 
considers  a  fracture  in  the  median  line  more  apt  to  unite  than 
one  at  the  side.  Tiie  cricoid  cartilaf^e  was  only  fractured  at  the 
side.  The  cricothyroidean  memVjrane  was  often  torn,  but  tiiat 
of  the  interior  of  the  larynx  was  found  intact.  In  a  case  in 
which  the  cadaver  was  hanged  by  a  rope,  the  larynx  was  frac- 
tured; in  another  it  was  uninjured.  In  violently  grasping  the 
throat,  the  larynx  could  be  broken,  provided  the  pressure  was  at 
the  upper  part.  Maclean  and  others  have  oljserved  laryngeal 
fracture  which  had  arisen  from  falls  against  some  hard  ol)j('ct,  as 
the  edge  of  a  box  or  a  table.  In  twenty-nine  cases  collected  by 
Hunt,  he  found  that  the  fracture  occurred  at  an  age  prior  to 
ossification  of  the  cartilage. 

The  mo.st  usual  fracture  of  the  larynx  is  that  in  wliich  the 
superior  cornua  of  the  thyroid  cartilage  are  broken;  and  this 
arises  as  follows:  in  pressure,  such  as  is  caused  b}'  hanging,  the 
cartilage  is  forced  backwards,  the  wings  are  separated  by  the 
vertebral  column,  and  the  upper  horns,  being  forced  against  the 
column,  are  broken.  And  at  the  same  time,  the  tliyrohyoidean 
membrane  being  stretched,  may  tear  off  one  or  both  horns  of  the 
OS  hyoides. 

Symptoms. — Cavasse  observed  the  following:  trouble  in  breath- 
ing, aphonia,  cyanosis,  swelling,  and  ecchymosis  of  blood  in  some 
cases.     There  is  expectoration  of  blood-stained,  foani}^  mucus. 

Palpation  of  the  laryngeal  region  detects  crepitus  or  undue 
mobilit}'  of  the  parts  composing  the  larynx.  Swallowing  is 
impossible  or  attended  with  great  trouble.  The  carotids  beat 
violently,  and  the  face  is  turgid,  or  perhaps  pale  from  compres- 
sion of  the  carotids. 

Laryngeal  fracture  is  exceedingly  dangerous.  Hunt  found 
that  death  occurred  in  seventeen  patients  in  a  series  of  twenty- 
nine  who  had  fractured  larynx;  and  the  cases  invariably  died 
in  whom  the  mucous  membrane  had  been  wounded  and  trache- 
otomy was  not  performed.  Death  is  not  unfrequent  from  partial 
or  complete  closure  of  the  laryngeal  canal;  in  some  recorded  cases 
death  immediately  followed  the  fracture. 

Treatment. — In  laryngeal  fracture  to  guard  against  asphyxia 
from  sudden  occlusion  of  the  air-canal,  tracheotomy  should  be 
performed  at  once,  and  a  canula  worn  until  the  broken  parts 
have  reunited.     If  the  ala  be  broken,  and   it  be  impossible  to 


STRANGULATION,    HANGING.  925 

otherwise  maintain  the  parts  at  rest,  then  a  resort  may  be  had  to 
metallic  ligature,  fine  silver  wire  being  used  for  the  purpose. 
As  a  rule,  it  is  enougfi  to  bring  the  parts  into  proper  site,  and 
enjoin  the  maintenance  of  rest.  Meantime  the  calibre  of  the 
laryngeal  canal  should  be  maintained  patent  by  means  of  the 
occasional  introduction  of  a  sound,  which  may  be  passed  througli 
the  mouth  from  above;  or  the  sound  can  enter  the  tracheal 
opening  if  the  latter  has  been  made  for  tracheotomy;  thus  doing, 
fragments  which  have  been  displaced  inwards  can  be  forced  out- 
wards, and  satisfactor}'^  calibre  preserved. 

Strangulation,  Hanging. — The  neck  is  the  site  of  parts  of  which 
the  functional  activity  is  essential  to  life,  viz.,  vessels  through 
which  blood  passes  to,  and  returns  from,  the  head;  the  air-canal 
through  wdiich  air  reaches  to  and  returns  from  the  lungs;  and 
nerves  which  are  concerned  in  respiration.  The  accessibility 
and  exposed  situation  of  these  structures  render  the  neck  the 
chosen  point  towards  wdiich  the  hand  of  Penal  -Justice,  as  well  as 
that  of  the  assassin  and  the  suicide,  are  directed  in  their  work  of 
abruptly  ending  life.  The  means  used  to  accomplish  this  fatal 
purpose  are,  in  the  main,  strangulation  and  hanging.  Though  the 
greater  portion  of  this  subject  falls  for  consideration  to  the  medi- 
cal jurist,  yet  it  claims  the  attention  of  the  surgeon  sufficiently 
often  to  be  entitled  to  a  chapter  in  a  work  upon  surgery. 

Laugier,  who  finds  a  marked  difterence  between  violence 
done  by  strangulation  and  by  hanging,  defines  strangulation  to 
be  "an  act  of  violence  consisting  in  constriction  exercised  directly 
on  the  front,  or  on  the  entire  circumference  of  the  neck;  and 
which  has  the  effect  of  so  compressing  the  vessels  and  the  air- 
canal  as  to  cause  death  through  the  sudden  suppression  of  the 
encephalic  circulation  and  the  respiration."  The  violence  may 
be  done  with  the  hands,  or  by  means  of  a  cord ;  that  done  with  the 
hands  is  wholly  homicidal;  that  with  a  cord  may  be  homicidal 
or  suicidal;  and  in  each  case,  the  work  may  be  complete  or 
incomplete;  if  done  with  the  hand,  one  or  both  hands  may  be 
used;  or  if  a  cord  be  used,  this  may  vary  in  size,  and  be  applied 
in  different  w^ays. 

The  amount  of  violence  necessary  to  cause  death  through 
strangulation  done  by  the  hands,  will  vary  with  the  subject. 
Thus  a  small  force  will  suffice  in  the  aged  subject,  in  the  one 
weakened  by  disease,  and  in  the  infant.  Likewise,  if  tlie  neck  be 
small  or  emaciated,  so  that  the  hands  can  grasp  it  in  its  entirety, 
death  can  be  caused  by  a  much  smaller  degree  of  force  than  when 


926  WOUNDS    OF    THE    NKCK. 

the  subject  is  strong,  or  lias  a  well-developed  neck.  The  com- 
pression may  be  done  with  both  hands,  wlien  the  neck  rests 
behind  ngainstsonie  hard  object;  and  the  pressure  may  be  back- 
wards and  laterally :  or  it  may  be  directly  backwards.  Again, 
it  may  be  made  with  one  hand  in  front,  and  while  the  other  sup- 
ports the  nucha.  Or,  instead  of  backward  compression,  the  force 
may  be  directed  upwards,  so  that  the  tongue  being  forced  against 
the  posterior  wall  of  the  pharynx,  death  results  from  occlusion  of 
the  larynx,  and  may  be  caused  thus  by  a  small  amount  of  force. 

Manual  compression  acts  mainly  on  the  larynx ;  the  carotid 
arteries,  which  share  in  the  violence  done  by  the  rope,  often 
escape  manual  violence.  Yet  a  singular  exception  to  this  was 
observed  by  Laennec,  in  which  the  larynx  escaped  and  the 
carotids  only  were  compressed. 

In  all  cases  in  which  the  violence  is  fatal,  the  result  is  accom- 
plished speedily  in  subjects  unable  to  resist;  death  is  less  rapid 
in  persons  who  are  able  to  resist. 

If  the  violence  be  done  by  a  partially  or  wlioU}''  encircling 
agent,  this  may  be  a  large  or  small  cord,  a  handkerchief,  or  a 
portion  of  clothing,  or  a  sheet.  Ingenuity  stimulated  by  the  fury 
of  purpose  which  animates  either  the  assailant  or  the  suicide, 
has  evinced  marvelous  invention. 

Faureand  Hoffman  have  experimented  in  this  field;  and  they 
found  that  the  fatal  phenomena,  whether  the  strangulation  be 
done  suddenly  or  slowly,  consist  first  in  the  induction  of  uncon- 
sciousness, which  deprives  the  victim  of  the  power  of  resistance; 
and  secondly,  in  the  occlusion,  partial  or  complete,  of  the  air- 
passage,  which  completes  the  destruction  of  life.  In  regard  to 
death  caused  by  strangulation  with  a  cord,  it  must  be  stated  that 
opinion  varies  as  to  whether  death  results  more  from  obstruction 
of  the  vessels,  or  of  the  air-passage;  each  opinion  has  as  active 
partisans  in  its  behalf,  as  has  the  subject  of  death  from  chloro- 
form, whether  the  fatal  work  be  mainly  due  to  action  on  the 
heart,  or  on  the  lungs.  In  whatever  way  death  bj^  strangulation 
arises,  local  traces  of  violence  can  be  found  on  the  neck,  and 
symptomatic  phenomena  remain  on  other  parts  of  the  body, 
the  leading  ones  of  which  are  the  following. 

The  face  of  the  strangled  subject  is  usually  found  swollen  and 
purplish  in  hue;  and  the  tinting  is  irregular,  or  mottled,  or 
marbled  in  dis[>osition.  Yet  in  case  of  death  having  been  rapid, 
the  face  may  be  })ale  or  colorless.  The  eyes  are  commonly  open, 
prominent  and  congested,  and  the  pupils  dilated.     The  tongue, 


STRANGULATION,    PIANGING.  927 

swollen  and  black,  may  be  found  between  the  teeth,  or  lying 
behind  them.  A  fluid  containing  blood  and  foamy  in  character 
escapes  from  the  mouth;  and  blood  has  also  been  seen  escaping 
from  the  ears.  According  to  Tardieu,  conditions  found  most  fre- 
quent are  multiple  ecchymoses  found  beneath  the  ocular  and 
palpebral  conjunctiva;  likewise  in  the  skin  of  the  face  and  neck. 
Contusions  or  marks  of  great  violence  from  the  efforts  of  the 
assailant  may  be  found  on  other  parts  of  the  body.  Special 
marks  of  violent  force  are  found  on  the  neck  and  throat,  which, 
in  form  and  location,  farnish  evidence  of  an  assailant's  hand. 
Prints  of  finger  nails  will  be  found;  and  such  being  usually 
made  with  the  right  hand,  they  are  chiefly  on  the  left  side  of  the 
subject's  neck. 

If  the  strangulation  has  been  done  with  a  rope  or  cord,  there 
will  remain  some  compression  of  the  latter  in  the  cervical  integu- 
ment; certain  professionals  in  the  hideous  work  of  strangling 
have  so  perfected  their  art,  in  the  use  of  a  broad  band,  that  scarcely 
any  outward  mark  remains  to  indicate  the  violent  work  which 
has  been  done.  In  the  use  of  the  ordinary  rope,  a  mark  corre- 
sponding to  its  breadth  or  narrowness  is  left  on  the  surface. 
Such  mark  made  by  the  strangler's  cord  usually  passes  horizon- 
tally over  the  larynx,  or  the  trachea;  but  the  hangman's  cord  is 
placed  obliquely,  and  is  usually  situated  above  the  larynx,  and 
between  it  and  the  hyoid  bone.  The  hangman's  cord  leaves  a 
deeper  impression  than  does  that  of  the  strangler;  for  in  the 
former  case,  the  weight  of  the  body  and  the  usually  longer 
continuance  of  the  violence  both  tend  to  deepen  the  furrows  on 
the  victim's  neck.  The  depression  of  the  hangman's  rope 
diminishes  from  before  backwards;  that  of  the  strangler  dimin- 
ishes from  behind  forwards. 

The  subcutaneous  structures  may  be  the  site  of  much  more 
violence  than  is  indicated  by  lesions  visible  on  the  surface;  the 
former  may  be  severely  bruised  or  torn,  while  the  skin  is  but 
slightly  injured.  Ecchymosed  blood  may  be  discovered  in  the 
intermuscular  spaces,  as  low  down  as  the  sternum.  The  hyoid 
bone,  larynx  and  trachea  have  been  the  site  of  fracture  from 
manual  strangulation:  no  infrequent  occurrence,  according  to 
Henocque.  Within  the  air-passage  there  is  found  ecchymosis  in 
the  mucous  membrane;  and  according  to  Tardieu,  an  invariable 
accompaniment  of  such  strangulation  is  a  sanguinolent  mucus 
studded  with  minute  bubbles,  lining  the  larger  air-passages. 

The  lungs  present  variable  apj^earances;  they  may  be  nearly 


028  WOUNDS   OF    THE    NECK. 

normal;  or  congestion  may  be  found;  and  most  frequently,  super- 
ficial air- vesicles  are  ruj)tured,  and  some  emphysematous  extrav- 
asation is  present;  and  from  this  condition  a  crackling  sound  is 
caused  when  pressure  is  made  on  the  part. 

In  the  encephalon,  marks  of  congestion  are  present,  or  slight 
apoplectiform  rupture  is  found. 

In  brief,  the  changes  which  are  found  in  tlie  body  after  death 
from  strangulation  are  sucli  as  should  arise  from  a  sudden 
obstruction  of  circulation  of  blood  in  the  cervical  vessels,  and 
an  arrest  of  the  passage  of  air  through  the  laryngo-tracheal 
canal. 

In  case  the  victim  has  survived  the  force  of  the  assailant, 
traces  of  the  violence  done  will  remain  on  the  body  of  the  subject. 
And  as  there  has  been  a  prolonged  struggle,  in  which  the  victim 
successfully  resisted  the  attack,  he  will  have  marks  of  the  same 
on  other  parts  of  the  body,  besides  the  usual  red  points,  or  abra- 
sions, about  the  neck.  In  one  case,  the  ears  of  the  woman  who 
survived,  had  been  torn  nearly  from  the  head.  It  has  also  been 
remarked  that  such  survivors  often  present  more  extensive 
ecchymoscs  on  the  neck  than  do  those  who  have  succumbed  to 
the  assault:  for  in  the  former,  the  blood  has  had  time  to  suffuse 
itself  within,  or  underneath  the  skin.  As  functional  symptoms 
there  are  present  the  following:  bloody  foam  is  escaping  from  the 
mouth  and  nose;  the  voice  is  altered,  broken  and  sometimes 
extinguished,  and  deglutition  is  interfered  with:  and  the.se  condi- 
tions may  continue  for  a  few  weeks.  And  from  the  contusion  of 
the  cervical  structures,  suppuration  may  arise. 

Again,  the  assault  may  only  be  of  momentary  duration,  and 
cause  syncope,  in  wliicli  the  subject  becomes  quite  unconscious 
for  a  short  time ;  or  the  unconsciousness  may  continue  longer, 
and  be  accomjjanied  by  convulsive  movement  of  the  muscles. 

Strangulation,  ordinarily  the  result  of  a  criminal  attack,  may 
arise  from  causes  purely  accidental;  and  in  the  latter  case,  the 
position  and  surroundings  of  the  dead  body,  would  aid  in  the  deter- 
mination of  the  mode  of  death.  If  the  work  be  that  of  a  criminal, 
the  number,  arrangement  and  deviation  of  the  lesional  marks  on 
the  neck,  indicate  the  relative  position  of  the  assailed  and  assail- 
ant. If  a  right  hand  has  done  the  violence,  there  will  be  found 
the  imprint  of  four  fingers  on  the  left  side  of  the  neck,  and  that 
of  the  thumb  on  the  right  side;  or  the  reverse,  if  the  a.ssailant  be 
left-handed. 

Strangulation  may  be  counterfeited :  for  example,  it  may  be 


HANGING.  929 

done  on  one  already  dead.  Yet  the  conditions  found  would 
differ  from  those  of  genuine  strangulation  in  this,  that  in  the 
former,  the  spots  of  ecchymosis  are  slight  or  wanting;  or  in  the 
event  that  the  work  of  fraud  has  been  done  so  soon  after  death 
that  ecchymosis  may  result,  yet  there  will  arise  no  swelling  of  the 
face,  nor  cyanosis  of  the  skin :  for  these  only  arise  from  violence 
done  during  life.  And  in  such  post-mortem  strangulation,  a 
necropsy  will  find  none  of  the  appearances  which  have  been 
mentioned  as  present  in  cases  in  which  the  strangulation  was  the 
fatal  agency. 

In  some  cases,  strangulation  has  been  done  by  some  one  upon 
himself  for  the  object  of  visiting  the  penalty  on  some  one  else,  on 
wliom  would  rest  the  suspicion  of  having  done  the  act;  and  such 
work  is  so  cunningly  planned,  that  the  expert  has  difficulty  in 
disentangling  the  plot;  and  especially  if  the  planner  has  tran- 
scended his  purpose,  in  actually  killing  himself.  The  impostor 
in  such  case,  less  wise  than  the  expert  who  afterwards  investi- 
gates his  work,  often  leaves  out  a  link  in  the  chain  of  evidence 
which  he  forges  against  the  would-be  assailant.  A  case  akin  to 
this,  was  that  of  the  colored  student  at  the  military  school  of  the 
United  States  a  few  years  ago.  He  was  found  tied  with  his  ears 
cut  off;  and  whether  this  mutilation  was  self-inflicted,  or  was 
done  by  his  j)ersecutors  as  he  claimed,  was  a  problem  which 
remained  unsolved  by  the  commission  of  inquisition;  his  friends 
believed  that  he  was  the  victim  of  a  brutal  outrage;  his  enemies 
declared  him  an  impostor,  and  that  his  deception  was  justly  paid 
for  by  the  forfeiture  of  his  ears. 

Hanging. — Hanging  is  defined  by  Laugier  to  be  an  act  in 
which  a  rope-like  cord,  which  is  attached  to  a  fixed  point,  is 
passed  around  the  neck,  when  the  body  being  abandoned  to  its 
own  weight,  traction  is  caused,  which  destroys  life,  through  either 
the  arrest  of  the  circulation  in  the  head,  or  by  the  closure  of  the 
air-passages;  or  death  may  arise  from  both  these  agencies.  Hang- 
ing differs  from  strangulation  only  in  the  direction  or  manner  in 
which  the  violence  acts;  the  weight  of  the  body  becomes  the 
agency  of  death.  This  act  is  oftenest  that  of  the  suicide;  of 
seventy-nine  thousand  five  hundred  fifty-seven  deaths  self- 
caused  collected  by  Brouardel,  nearly  one-half  were  caused  by 
hanging  or  strangulation;  and  nearly  thirty  thousand  of  this 
number  were  men. 

The  subjective  phenomena  of  hanging  have  been  learned 
from  the  experience  of  those  in  whom  the  fatal  purpose  failed  of 


930  WOUNDS    OF    THE    NECK 

completion  ;  and  who  recovering  were  able  to  narrate  their  sen- 
sations. And  Fleischmann,  a  zealous  student  of  the  subject,  stud- 
ied his  own  sensations  after  suspension  for  a  brief  time;  and  the 
following  has  been  reported  by  Laugier  concerning  this  matter: 
The  instant  the  body  is  suspended  and  abandoned  to  its  own 
weight,  the  face  reddens  and  the  head  is  hot,  and  there  is  a  gen- 
eral sensation  of  heat  through  the  entire  body;  there  is  a  hissing 
and  buzzing  in  the  ears,  sometimes  amounting  to  loud  noises, 
like  some  loud  music;  the  legs  feel  exceedingly  heavy ;  finally, 
all  sensation  vanishes.  In  some  cases,  the  first  })lienomenon  is 
total  syncope,  in  which  consciousness  is  lost  at  once.  The  popu- 
lar idea  propagated  by  a  few  writers,  that  in  the  first  moments 
of  suspension  the  subject  experiences  voluptuous  sensations,  is 
incorrect ;  the  seminal  escape  sometimes  seen,  occurs  when  the 
patient  is  in  an  unconscious  condition. 

The  I0.SS  of  consciousness  which  takes  place  in  the  first  period 
of  hanging  is  soon  succeeded  by  a  convulsive  stage,  in  which  the 
muscles  of  the  face  and  eyes  are  distorted,  and  the  limbs  are 
spasmodically  moved.  The  suspended  one  striking  his  feet 
against  the  floor  or  wall  has  apprised  those  near  by  of  his 
suicidal  act. 

HolTmann  and  Amussat  have  studied  the  efiect  on  the  cer- 
vical vessels  of  hanging;  and  tliey  have  found  that  the  internal 
and  middle  tunics  of  the  carotids  are  often  lacerated.  They 
have  likewise  discovered  that  when  the  loop  of  the  cord  is  placed 
near  the  cliin,  the  effect  is  to  arrest  the  flow  of  the  blood  through 
the  carotid  arteries,  even  when  the  body  is  but  imperfectly  sus- 
pended. Hoft'mann  states  that  when  the  rope  is  above  the  lar- 
ynx, that  is  between  the  larynx  and  hyoid  bone  (its  usual  site  in 
hanging),  the  larynx  is  not  closed  by  compression  on  it,  but 
through  the  root  of  the  tongue  being  forced  against  the  posterior 
wall  of  the  pharynx  so  as  to  close  the  passage.  This  he  found 
in  section  of  frozen  cadavers.  Brouardel  in  experimenting  in 
this  field,  finds  that  suspension  can  be  done  in  such  a  mantier 
that  blood  may  continue  to  flow  through  one  carotid  while  the 
other  is  closed. 

Hoffmann  has  also  directed  attention  to  the  efiect  of  the  com- 
pression of  the  rope  on  the  nerves  of  respiration  which  lie  in  the 
neck;  he  probably  overestimates  this  action:  since  the  jiressure 
on  the  vessels  and  air-pnssages  is  sufficient  to  destroy  life  inde- 
pendently of  any  action  on  the  adjacent  nerves. 

In  case  of  fracture  of  one  or  more  of  the  upper  cervical  verte- 


HAXGIXG.  031 

bne,  there  may  be  injury  done  to  the  medulla  oblongata,  which 
will,  at  once,  destroy  life;  such  cases  are  rare,  yet  when  they 
happen,  death  occurs  independently  of  any  obstruction  of  the 
air-canal  or  blood-vessels. 

Sudden  death  has  also  been  seen  as  the  result  of  syncope 
from  the  instant  induction  of  cerebral  anaemia  through  closure 
of  the  vessels;  the  face  of  the  cadaver  in  such  cases  presents  a 
waxen  discoloration.  On  the  contrary,  if  the  cord  is  so  placed  as 
to  close  one  carotid  and  permit  the  passage  of  some  blood  through 
the  other  artery,  and  at  the  same  time,  the  jugular  veins  do  not 
allow  the  return  of  the  blood,  then  death  will  occur  slowly, 
through  congestive  apoplexy;  in  such  subjects,  the  face  will  be 
cyanosed  or  purple.  Such  cases  are  those  in  which  resuscitation 
is  possible;  while  in  those  in  whom  death  is  in.stantaneou.s, 
according  to  Brouardel,  life  cannot  be  recalled.  Xotwith.standing 
this  eminent  authority,  an  attempt  should  be  made  to  resuscitate 
in  all  cases;  for  failure  cannot  make  the  unfortunate  subject's 
condition  any  worse. 

In  a  small  number  of  cases  observed,  the  violence  done  has 
not  destroyed  life  at  once;  the  patient  found  suspended  was  dis- 
covered before  life  was  extinct,  and  an  attempt  to  resuscitate  has 
been  partly  succe.ssful;  yet  after  some  hours,  or  even  days,  death 
sometimes  ensued.  In  one  such  subject  who  lived  twenty-four 
hours,  the  body  ne\^r  became  warm.  The  necropsy  revealed  no 
other  lesion  than  an  intense  encephalic  congestion.  And  in 
another  case  the  attempt  at  suicide  was  not  immediatel}^  success- 
ful. The  skin  of  the  face  was  red  and  swollen;  resj^iration  and 
circulation  were  restored.  Later,  there  appeared  hemiplegia, 
also  muscular  oentracture;  and  finally,  the  patient  returned  to 
consciousness  and  was  able  to  speak  rationally;  on  the  sixth  da}^ 
he  died,  with  sym])toms  of  pronounced  meningo-encephalitis. 

From  those  who  have  recovered  after  temporary  hanging 
some  knowledge  has  been  derived;  the  sensations  remembered 
were  those  which  have  been  mentioned  above;  and  in  one  who 
recovered,  the  subsequent  symptoms  were  loss  of  memorv,  voice 
nearly  extinguished,  incontinence  of  urine  and  paralysis  of  the 
rectum,  sharp  pains  and  convulsive  movements  of  Vne  limbs; 
likewise,  cough  and  bronchial  catarrh  with  dyspnoea.  In  another 
case  there  remained  pains  in  the  head,  giddiness  and  trouble  of 
swallowing. 

The  ])atient  in  one  case  was  rescued  after  being  suspended 
seven   minutes.     Taylor   thinks    recall    to   life   is  pos.sible  after 


932  vvOUXDS   OF    THE    NECK. 

Imnging  five  minutes.  It  is  clear  that  the  time  is  subject  to 
variation,  dependent  on  the  manner  in  which  the  rope  has  been 
adjusted  about  the  neck,  and  also,  whether  there  has  been  a  fall 
along  with  tiie  suspension.  A  fall  of  the  body  through  a  fen' 
feet  after  the  cord  has  been  fixed  around  the  neck,  becomes  the 
more  important  factor  in  the  fatal  work.  This  has  been  verified 
in  the  work  of  judicial  hanging:  the  long  space  through  which 
the  body  has  dropped  has  frequently  caused  the  cord  to  make  a 
deep  cut  in  the  structures  included;  and  in  one  case  known  to 
the  writer,  the  work  was  so  eifectually  done  tlint  the  head  was 
severed  from  the  body  in  the  fall. 

General  facts  of  cardinal  importance,  to  which  reference  has 
been  made,  are  that  if  the  suspension  has  been  brief,  and  the 
death  immediate,  the  face  is  pale  and  of  natural  api)earance,  the 
eyes  half  closed  and  the  lips  are  discolored  without  swelling; 
but  where  the  dying  has  been  slow,  then  the  face  will  be  found 
cyanosed  and  swollen. 

Death  has  often  occurred  when  the  body  had  not  been  totally 
suspended;  life  has  been  extinguished  where  the  body  was  partly 
supported  by  the  feet;  also  in  cases  of  half  reclination,  either  in 
the  supine  or  prone  position. 

Epicharis,  one  of  the  conspirators  against  Nero,  after  being 
terribly  tortured  to  extort  her  secret,  destroyed  wliat  life  remained 
in  her  by  sitting  in  a  chair  and  passing  hei*head  through  a  loop 
of  her  girdle,  and  attaching  the  latter  to  the  top  of  her  chair. 
"Thus  dying,  she  put  to  shame  many  men  who  hastened  to 
betray  their  fellow  accomplices."     (Tacitus.) 

The  im})ression  made  by  the  suspending  cord  has  been  care- 
fully studied;  and  this  may  be  slight;  it  may  also  be  abseiit,  or 
it  may  be  distinctly  formed;  and  in  certain  circumstances  the 
cord  may  cut  or  tear  the  structures  of  the  neck. 

The  impression  has  been  so  slight  that  it  was  not  discoverable; 
thus  a  broad  or  elastic  band  may  leave  no  trace  of  its  action;  yet 
usually,  there  may  be  detected  some  red  discoloration  of  the 
derm;  however,  the  interposition  of  a  dense  beard,  or  a  thick 
cravat,  or  a  layer  of  clothing,  may  render  the  impression  of  the 
cord  invisible.  These  cases  are  ujiusual,  and  the  rule  is,  that 
the  rope  or  suspending  agent  leaves  a  clearly  discernible 
furrow  on  the  neck,  of  which  the  site,  direction,  form  and  depth 
have  been  carefully  studied. 

In  most  cases  this  cord-mark  passes  transversely  over  the 
front  of  the  neck,  between  the  larynx  and  the  chin.     In  a  col- 


HANGING.  933 

lection  of  one  hundred  fifty-sis  recorded  cases,  the  furrow  was 
found  in  one  liundred  twenty-seven  cases  above  the  larynx, 
and  oftenest  between  the  larynx  and  the  hyoid  bone;  in  twenty- 
six  cases  the  mark  was  on  the  lar^mx,  and  in  six,  it  was  below 
the  lar3^nx.  And  the  furrow  was  always  lower  down  when  the 
subject  was  in  oblique  suspension. 

The  furrov/  commencing  at  the  h3'oid  region  ascends  upwards 
and  backwards  behind  the  mastoid  processes  to  some  point  on 
the  nucha,  where  the  ends  of  the  cord  meet  in  the  closing  knot; 
and  if  the  knot  is  near  the  median  line,  behind,  then  the  figure 
of  the  imprint  will  be  that  of  an  ellipse,  which  opens  somewhat 
above  and  behind.  The  figure  will  be  less  regular,  if  the  knot  is 
at  the  side  of  the  nucha.  And  if  the  knot  be  near  the  ear,  then 
the  action  of  the  cord  will  be  oblique  and  irregular,  and  the  com- 
pression may  thus  occlude  one  carotid,  and  permit  the  passage  of 
some  blood  through  the  other  vessel. 

The  form,  breadth  and  depth  of  the  furrow  depend  on  the 
form  of  the  cord.  A  cord  passed  twice  around  the  neck  may 
.produce  a  double  impression ;  and  these  may  be  adjacent,  or  have 
an  irregular  interval  between  them  ;  or  if  a  hard  broad  band,  as 
one  of  leather,  be  used,  then  its  two  edges  may  leave  impressions, 
which  are  parallel. 

The  breadth  of  the  furrow  is  generally  less  than  that  of  the 
constricting  cord;  and  the  depth  is  directly  proportional  to  the 
thinness  of  the  cord  and  the  time  that  the  suspension  is  continued. 
The  greater  the  development  of  the  fatty  couch  is,  the  deeper 
will  be  the  furrow  produced  by  the  cord.  If  the  cord  have  knots 
or  other  irregularities,  these  Mall  be  represented  in  the  furrow. 

As  to  the  color  of  the  imprint  caused  by  the  constricting 
agent,  this  depends  on  its  depth,  and  whether  the  bottom  of  the 
sulcus  is  soft,  or  dry  and  parchment-like.  If  there  be  no  depres- 
sion, the  skin  may  remain  of  natural  tint.  But  when  there  is  left 
a  decided  furrow  which  is  soft,  tliis  will  be  of  a  pale  white  color: 
in  fact,  whiter  than  the  parts  adjacent.  Instead  of  a  white  hue 
this  may  be  a  dirty  blue,  due  to  a  thinning  of  the  skin,  which 
permits  the  color  of  the  subjacent  muscles  to  be  perceptible,  or 
the  attenuated  and  condensed  skin  may  assume  a  bluish  tint. 

The  skin  lining  the  furrow  may  be  dry  and  parchment-like, 
and  then  the  color  may  be  an  orange-yellow,  or  a  reddish-brown. 
Again  the  dried  compressed  skin  may  have  a  shining  or  pearly 
hue.  The  borders  of  the  furrow  are  slightly  elevated,  and  of  a 
violet  hue,  dependent  on  a  superficial  congestion  of  the  derm. 


914  AVOUXDS   OF    THK    NECK, 

If  the  air  be  very  moist,  this  desiccation  does  not  take  place ;  and 
for  its  full  a[)pearance,  the  furrow  must  be  exposed  some  time  to 
the  dr}'  atinos})here. 

To  obtain  the  discolored  })archment-like  furrow,  the  following 
j)roliminary  conditions  are  needed:  suspension  with  a  cord  that 
will  produce  a  depression;  the  cord  must  maintain  pressure 
enough  to  force  the  blood  from  the  walls  of  the  fiirrow  ;  and  after 
the  removal  of  the  cord,  the  part  must  be  exposed  sometime  to  a 
dry  air. 

Hoffmann  has  examined  a  great  number  of  bodies  of  young 
and  vigorous  men  wiio  had  died  by  hanging,  and  in  no  one  did 
he  find  penile  erection.  In  case,  however,  the  bod}'  had  remained 
hanging  for  a  considerable  time  after  death,  then  there  was  found 
genital  turgescence,  which  he  referred  to  hypostatic  congestion. 
Tardieu  is  not  so  positive  on  this  point;  he  admits  the  possibility 
of  genital  erection,  as  a  reflex  act  awakened  by  the  violence  done 
to  the  upper  part  of  the  spinal  cord.  And  admitting  the  possi- 
bility of  such  reflex  action,  which,  as  stated,  has  been  denied  by 
most  observers,  there  are  two  species  of  genital  turgescence  which 
may  follow  hanging,  the  one  wliicli  is  found  immediately  after 
death :  and  that  which  occurs  later,  and  is  purel.y  a  physical 
condition,  the  result  of  the  position  of  the  body ;  and  in  case  the 
former  occurred,  the  latter  might  follow  it  some  time  afterwards, 
provided  the  body  remained  in  suspension. 

Luxation  or  fracture  of  the  upper  cervical  vertebrse  was  not 
seen  by  Casper,  Tardieu  and  Hoffmann  in  cases  of  suicidal  hang- 
ing; it  was  only  seen  in  the  neck  of  the  hanged  criminal ;  and 
occurred  oftener  in  former  times  than  at  present,  when  the  work 
is  done  with  more  complaisance  to  the  victim. 

Besides  the  violence  done  by  the  suspension,  the  body  of  the 
subject  may  present  other  marks  of  violence;  thus  there  may  be 
found  contusions  of  surface,  costal  fracture  and  other  lesions 
which  arose  during  the  struggle  in  which  the  victim  w^is  over- 
powered. And  marks  of  wounds  received  some  days  prior  to  the 
hanging  may  exist.  Such  injury  will  have  characteristics  which 
will  indicate  its  age. 

The  body  being  found  hanging,  it  is  often  a  question  of 
importance  in  forensic  medicine  to  determine  how  long  the  body 
had  been  suspended;  and  this  question  is  still  more  important  to 
those  on  whom  devolve  the  task  of  resuscitation.  If  the  body  be 
yet  warm,  and  the  suspension  has  been  incomplete,  or  there  has 
been  no  fall,  then  an  attempt  is  to  be  made  to  recall  the  victim, 


IXSUFFLATIOX.  935 

provided  he  be  not  in  tlie  list  of  those  ^vhose  Hfe  has  been  for- 
feited through  crime;  the  death  of  the  latter  being  decreed  by 
the  law,  he  is  denied  the  privilege  which  the  merciful  hand  of 
medicine  extends  to  him  who  is  the  victim  of  suicidal  or  homi- 
cidal violence.  A  consideration  of  the  means  of  i^estoration  here- 
with follows. 

Artificial  Besjjiration. — -The  principal  means  of  resuscitation  of 
the  subject  which  has  been  the  victim  of  strangulation  or  sus- 
pension, is  that  of  artificial  respiration.  And  this  is  also  resorted 
to  in  those  who  are  seemingly  dead  from  immersion  in  water  or 
semi-liquid  materials;  or  whose  air-passages  have  been  occluded 
by  earth,  sand  or  other  means;  or  where  breathing  has  been 
nearly  or  ciuite  arrested  by  a  narcotic  or  an^stlietic  agent,  or  an 
asphyxiating  gas;  in  all  such  cases,  it  is  possible  to  relight  or 
reanimate  the  expiring  spark  of  life  by  resorting  to  artificial 
respiration:  by  which  is  meant  the  alternate  introduction  of  air 
into,  and  its  expulsion  from,  the  lungs. 

Resuscitation  of  the  subject  vrho  is  apparentl_y  dead  from  any 
of  these  causes  may  be  attempted  by  several  methods.  If  life  be 
realh'  extinct,  it  will  be  indicated  b}^  certain  signs,  among  which 
may  be  enumerated  rigor  mortis  and  loss  of  the  contractile  |)Ower 
of  the  pupil.  If  the  cornea  of  the  dead  subject  be  pressed  on,  the 
pupil  v\-ill  be  displaced,  and  its  circular  form  converted  into  an 
irregular  one,  which  remains.  And  finally,  if  signs  of  decompo- 
sition are  present,  these  denote  that  the  undertaker's  duties 
rather  than  tho.se  of  the  resuscitator,  are  demanded:  for  then,  in 
the  words  of  the  great  Dramatist,  medicine  "knows  not  where  is 
that  Promethean  heat  that  can  this  light  relume.'"' 

As  resuscitating  methods,  the  following  may  be  named :  (1)  in- 
sufflation, or  blowing  the  air  into  the  lungs;  (2)  aspiration,  in 
which  the  thoracic  cavity  is  enlarged  by  some  procedure  so  that 
the  air  spontaneously  enters  the  air-passages,  and  then  by  revers- 
ing the  procedure,  the  air  is  expelled ;  (3)  intermittent  pressure 
on  the  cardiac  region;  (4)  rhythmical  extraction  and  retraction  of 
the  tongue;  (5)  electrical  excitation  of  the  respiratory  nerves. 

Insufflation. — Of  all  the  means  employed  to  restore  the  inani- 
mate to  life,  insufflation  is  probably  the  oldest.  Traces  of  this 
method  are  manifest  in  the  Biblical  account  of  Elisha  recalling  to 
life  the  widow's  son.  Insufiiation  may  be  done  orally,  in  which 
air  is  blown  from  mouth  to  mouth,  the  nostrils,  meantime,  being 
occluded;  or  it  may  be  done  with  a  tube  which  is  passed  through 
the  mouth  into  tlie  larynx,  or  into  the  mouth  simply,  or  into  one 


930  WOUNDS    OF    THE    NECK. 

nostril,  the  remainder  of  the  nose  and  mouth  being  closed.  An 
instrument  Avliicli  may  be  carried  into  tlie  larynx  is  a  common 
male  catlieter,  either  of  silver,  or  of  gutta  percha.  This  is  a  good 
means  of  reviving  tlie  still-ijorn  infant,  which  the  author,  on 
several  occasions,  has  employed  successfully.  A  gntta  percha 
catheter  of  smallest  calibre  should  be  used.  To  do  this  work 
properly,  some  preliminary  practice  must  be  had  on  the  cadaver; 
the  index  must  be  trained  to  find  the  opening  into  the  glottis, 
which  is  distinguished  by  its  hard,  cartilaginous  borders.  The 
end  of  the  left  index  being  fixed  in  this  o})ening,  the  catheter  can 
be  carried  along  the  palmar  side  of  the  bent  finger,  and  readily 
introduced  into  the  air-passage.  It  should  be  carried  into  the 
upper  part  of  the  trachea,  and  then  external  compression  being 
made  so  as  to  close  the  trachea  around  it,  the  air,  with  moderate 
force,  is  to  be  blown  into  the  lungs.  If  this  work  be  proper!}'' 
executed,  the  chest  will  dilate  as  in  normal  inspiration,  and  when 
this  has  readied  average  expansion,  the  walls  must  be  compressed 
to  expel  the  air;  thus  inspiration  and  expiration  are  represented, 
and  should  be  repeated  twenty  tin'ies  in  the  minute.  The  rigidity 
of  the  walls  of  the  trachea  and  larynx  of  the  adult,  as  well  as  the 
longer  distance  which  must  be  traversed  to  reach  the  part,  and 
also  the  contracture  of  the  muscles  which  close  the  lower  jaw, 
render  the  introduction  and  use  of  such  a  tube  difficult  in  the 
adult  or  aged  subject.  And,  as  an  easier  way  of  doing  the  work, 
jNIarchand  advises  to  pass  a  tube  into  one  nostril,  and  then  clos- 
ing the  other  and  the  mouth,  the  air  can  be  blown  into  tiie  nostril 
and  can  thus  be  made  to  descend  to  the  lungs.  As  a  tube  wliich 
is  usually  at  hand,  and  can  easily  be  used,  is  the  common  pipe- 
stem.  Marchand  commends  this  means  of  insufflation  above  all 
others;  and  he  i:»ronounces  it  superior  to  all  other  methods  of 
artificial  respiration.  The  air  from  an  clastic  balloon  can  be 
utilized;  or  the  operator  can  force  the  air  from  his  own  chest  into 
that  of  the  patient;  and  if  the  operator  takes  pains  to  forcibly 
expire  and  then  deeply  inspire,  the  air  used  will  be  sufficiently 
free  from  carbonic  acid. 

Objection  to  insufflation  is  that  the  air  may  jiass  through  the 
oesophagus  to  the  stomach,  and  filling  this,  the  movement  of  the 
diaphragm  is  interfered  Avitli.  This  is  true,  especially  if  the  air 
be  blown  from  mouth  into  mouth ;  the  writer  has  seen  the  stom- 
ach of  a  new-born  child  greatly  distended  in  this  way.  Another 
objection  is  that  air  thus  violently  forced  into  the  lungs  may 
rupture  the  pulmonary  tissue:  and  that,  after  resuscitation  in  this 


IXSUFFLATION.  937 

T\-ay,  there  may  remain  an  emjjhysematous  condition  of  the 
lungs.  Observation  and  experimentation  on  this  subject  are  dis- 
cordant. Thus,  Dumeril  and  Magendie,  appointed  a  commission 
to  report  on  this  method,  say  that  they  have  seen  fatal  laceration 
of  the  lungs  in  animals  thus  operated  on;  and  they  have  seen 
similar  lesions  iu  cadavers  subjected  to  such  insufflation.  They 
admit,  however,  that  insufflation  in  the  apparently  dead  subject, 
and  in  the  living  robust  one,  is  a  different  procedure:  the  former 
passively  admits  the  air,  while  the  latter,  if  an  animal,  vehemently 
resists  It.  And  the  commission  also  found  that  lesion  of  pulmo- 
nary tissue  was  only  seen  in  cases  in  which  the  air  had  been 
forced  in  continuously,  and  with  violence.  Depaul,  who  exam- 
ined this  question,  found  that  the  fears  of  injuring  the  lungs  are 
baseless,  provided  an}^  prudence  be  used  in  the  work;  and  the 
experiments  of  Budin  confirmed  the  statement  of  Depaul.  His 
experiment  consisted  in  attaching  a  large  inflated  bladder  to  the 
lungs  of  a  cadaver;  a  board  was  placed  on  tlie  bladder,  and  two 
jDersons  sat  on  this,  so  as  to  force  the  air  into  the  lungs;  such  vio- 
lence repeated  on  several  lungs,  only  caused  a  slight  injury  in 
one  case.  The  practical  conclusions  deducible  from  these  exper- 
iments and  observations  are,  that  insufflation  practiced  either  by 
the  mouth  or  an  instrumental  appliance,  is  safe  wdaen  the  work 
is  done  gently  and  with  rhythmical  interruptions.  Instead  of 
insufflation  through,  the  nostrils  or  mouth,  the  air  may  be  blown 
through  a  canula  or  tube,  wdiich  has  been  introduced  directly 
into  the  trachea  after  the  performance  of  tracheotomy.  This 
plan  has  been  advocated  by  Hueter :  and  as  special  advantage 
which  he  claims  for  it  is,  that  by  means  of  the  tube,  mucus  and 
other  obstructing  materials  can  be  withdrawn  from  the  air- 
passage. 

In  a  case  in  whicli  the  patient  had  apparently  died  from  an 
ansesthetic,  the  writer  rescued  the  man  by  quickly  plunging  a 
pocket  scalpel  into  the  trachea,  and  inserting  a  silver  catheter, 
through  which  air  was  blown  into  the  lungs.  Breathing  for 
nearly  an  hour  was  very  slow:  yet  by  persevering  effort,  the 
patient's  life  was  saved. 

Against  insufflation  Pacini  urges  that  it  is  the  reverse  of  the 
ordinary  respiratory  act,  viz.,  in  this  artificial  procedure  the  air 
being  forced  in  increases  the  pressure  in  the  lungs;  while  in 
natural  breathing  there  is  a  diminution  of  pressure.  In  the 
former  condition,  the  carbonic  acid  contained  in  the  blood  has 
no  tendency  to  escape,  and  the  pulmonarv  capillaries  are  in  a 
60 


938  WOUNDS    OF    THE    NECK. 

slate  of  compression;  the  heart,  also,  is  pressed  on,  and  is  interfered 
with,  in  its  normal  action.  Though  these  objections  are  not 
groundless,  yet  Pacini  gives  them  too  much  importance  when  he 
says  that  the  method,  instead  of  saving,  destroys  life.  That  life 
may  be  revived  by  insufflation  is  shown  in  the  observation  of 
Guerard,  that  of  one  hundred  and  eighty-five  persons  immersed 
in  water  who  were  restored  to  life,  in  fifty-four  cases  insufflation 
was  the  only  means  employed. 

Aspiration. — By  the  method  of  aspiration  the  thorax  is  dilated; 
and  this  may  be  accomplished  by  several  methods:  among  these 
may  be  mentioned  the  plan  of  removing  the  pressure  from  the 
outside  of  the  chest,  so  that  a  species  of  vacuum  is  created  in  the 
thorax;  or  this  may  be  done  by  pressure  so  as  to  lessen  the  tho- 
racic space,  which  reexpanding  forms  a  partial  vacuum  ;  or  by 
traction  on  the  arms,  so  as  to  dilate  the  thoracic  cavity. 

The  first  method,  by  which  there  is  formed  a  partial  vacuum 
within  the  chest,  has  been  accomplished  by  means  of  a  somewhat 
complicated  apparatus  invented  by  AVoillez,  and  named  spiro- 
phore, a  hybrid  name.like  too  many  others,  compounded  from  the 
Latin  and  Greek.  This  consists  of  a  metallic  envelope  of  cylin- 
drical form,  into  whicli  the  body  is  to  be  introduced,  except  the 
head,  which  is  exposed.  Around  the  neck  there  is  placed  some 
flexible  material,  which  hermetically  closes  the  metallic  cylinder. 
To  the  lower  part  of  the  apparatus  an  air-extractor  of  bellows- 
form  is  attached.  Bv  the  aid  of  the  extractor,  the  air  can  be 
removed  from  the  interspace  between  the  body  and  the  cylinder, 
so  that  the  chest  is  caused  to  dilate,  and  air  is  thus  drawn  tlirough 
the  nostrils  and  mouth  to  the  lungs.  And  by  a  reverse  action  of 
the  extractor,  the  air  can  be  expelled  from  the  lungs.  Thus,  as 
seen,  the  two  actions  of  inspiration  and  expiration  are  imitated: 
and,  as  AVoillez  found,  two  pints  of  air  can  be  aspirated. 

This  method  has  its  analogue  in  action  in  a  corset-like  appli- 
ance, which  being  provided  with  straps  and  buckles,  and  placed 
around  the  thorax,  by  alternately  tightening  and  relaxing,  the 
space  within  the  chest  is  lessened  or  increased.  This  plan  was 
examined  by  the  Royal  Humane  Society  of  London,  but  its  use 
as  a  means  of  resuscitation  was  not  advised.  In  fact,  any  means 
which  is  similar  to  the  methods  mentioned,  is  open  to  the 
fatal  objection  that  time  is  lost  in  its  application:  the  minutes 
which  must  be  consumed  iu  applying  the  vacuum  cylinder  of 
AVoillez,  or  the  corset  girdle  of  Leroy  d'fitiolles,  are  those  precious 
moments  in  which  tlie  resuscitator  has  the  only  opportunity  of 


ARTIFICIAL    RESPIRATION. 


939 


rescuing  the  victim :  before  such  meclianical  device  can  be  placed 
in  proper  position  for  use,  the  latent  spark  of  life  will  be  wholly 
extinguished. 

A  method,  celebrated  and  commended  bv  the  Royal  Humane 
Society,  is  that  of  Marshall  Hall,  in  which  the  body  is  so  placed 


that  by  rolling  movements  the  chest  cavity  is  alternately  lessened 
and  enlarged;  and  this  is  done  as  follows:  the  subject  being 
placed  on  a  flat  surface,  is  first  turned  so  that  the  face  is  prone, 
and  the  chest  rests  on  a  cushion;  and  while  in  this  posture,  the 
mouth  should  be  opened,  tongue  drawn  forwards,  and  mucus 
and  other  material  wiped  from  the  buccal  cavity:  also,  pressure 


940 


^vou^•I)S  of  the  nkck. 


1    nn  the  back  between  the  shoulder-blades.     From 
should  be  made  on  he  back  b  ^.^^^  ^^.^^.^^^  ^.^^^^  ^^^ 

a  cushion,  and  while  thus     ace  {  ,i,,  thoracic  space, 

on  the  upper  or  exposed  side,  so  as 


ARTIFICIAL    RESPIEATIOX. 


941 


•  something  analogous,  is  shaped  into  a  cushion,  and  placed 
beneath  tlie  stomach,  while  the  subject  is  turned  with  face  and 
chest  downwards;  in  this  position,  the  tongue  being  drawn  for- 
ward, the  buccal  cavity  is  freed  from  all  extraneous  material; 
and  in  this  posture  liquid  material  lodged  in  the  throat,  or  air- 
passages,  will  flow  from  the  mouth.  The  body  is  next  turned  on 
the  back,  which  rests  on  the  cushion;  the  hands  are  uplifted, 
crossed  and  placed  underneath  the  subject's  head,  and  retained 
there  by  an  aid,  who  also  holds  the  protruded  tongue.  The  sur- 
geon kneeling  b;/  the  patient,  grasps  and  compresses  the  thorax 
on  each  side  at  its  lower  portion,  and  continues  this  for  three 
seconds;  then  he  suddenly  relaxes  his  hold,  when  the  air  rushes 
into  the  expanding  chest.  Thus  expiration  and  inspiration  are 
represented.  Howard  names  his  plan  the  "direct  method,"  and 
he  claims  for  it  advantages  over  all  the  others. 

The  next  method  to  be  considered  is  that  of  Silvester,  exhib- 
ited in  Figure  9S,  which  is  executed  as  follows:  the  patient  is 


FiGUEE  98.     Showing  Silvester's  method   of  artificial  respiration.      From 
Harley ;  Holmes'  Surgery. 

placed  on  his  back  with  a  small  supporting  cushion  under  the 
chest.  The  mouth  and  nostrils  must  be  freed  from  all  extrane- 
ous matters.  The  tongue  must  be  somewhat  withdrawn,  and 
held  so  as  to  retain  the  pharynx  open.  The  surgeon  now  stands 
behind  the  head  of  the  patient,  and  to  do  so,  the  latter  should  lie 
on  a  table,  at  the  head  of  which  the  surgeon  stands,  while  the 
one  retracting  the  tongue  occupies  a  lateral  position  towards  the 
feet  of  the  patient:  if  he  stands  near  the  chest,  he  will  be  in  the 


042  WOUNDS   OF    THE    NECK. 

way  of  the  operator.  This  the  writer  has  learned  from  ex[)eri- 
ence;  and  also,  that  instead  of  elevating  the  chest  as  Silvester 
does,  it  is  better  to  lower  the  head,  so  that  the  blood  will  easily 
rcach  the  brain.  The  operator  now  raises  the  extended  arms 
above  the  head  and  makes  some  traction  on  them,  during  a  period 
of  two  seconds;  then  the  arms  are  lowered,  and  flexed  at  the 
elbows,  wliich  with  the  upper  arms  are  to  be  forced  against  the 
sides  of  the  tliorax.  The  upward  traction  of  the  arms  acts  on  the 
chest  through  the  following  muscles,  which  have  costal  attach- 
ment :  the  pectoralis  major  and  minor  muscles  in  front;  the  serra- 
tus  magnus  muscle  at  the  side,  and  the  latissimus  dorsi  muscle 
behind  ;  the  one  which  aids  most  efficiently  is  the  serratus  mag- 
nus, which  extending  from  the  posterior  border  of  the  scapula 
and  being  attached  to  eight  ribs,  is  tlie  medium  through  which 
much  costal  elevation  can  be  effected.  Since  this  muscle  lies 
somewhat  obliquely,  to  bring  it  into  full  action,  the  arms  must 
be  drawn  upwards  and  somewhat  backwards;  and  these  move- 
ments should  be  repeated  about  fifteen  times  each  minute,  to 
correspond  to  normal  breathing. 

Though  the  method  of  Silvester  is  simple,  yet  the  first  time 
it  is  attempted,  it  will  be  awkwardly  done,  as  the  writer  l)as 
observed  in  his  collegiate  instruction;  to  be  well  done,  .some  pre- 
vious training  is  necessary. 

This  method  was  examined  by  the  Medico-Ciiirurgical  Society 
of  London,  and  pronounced  superior  to  that  of  Marshall  Hall; 
by  Hall's  plan  only  ten  cubic  inches  of  air  were  taken  into  the 
lungs,  while  by  that  of  Silvester,  the  amount  was  from  thirty  to 
fift}'  cubic  inches.  It  was  also  found  that  if  rigidity  of  the  mu.s- 
cles  existed  in  the  commencement,  this  vanished  as  the  proce- 
dure was  continued,  .so  that  the  amount  of  air  that  was  drawn  in 
at  tlie  close  of  the  movements  was  nearly  double  that  which  it 
was  at  the  commencement.  It  has  also  an  advantage  over  Hall's 
method  in  this,  that  both  sides  of  the  chest  are  acted  on  uni- 
formly, while  in  the  former,  tiie  action  is,  in  a  measure,  limited 
to  one  side. 

Pacini  has  introduced  a  method  somewhat  similar  to  the  last 
described:  the  patient  is  stripped  and  placed  on  his  back,  and  the 
buccal  cavity  1)eing  liberated  of  all  materials,  the  operator  seizes 
the  shoulders  above  with  the  hands,  so  that  tlie  thumbs  pa.ss  in 
front  and  the  fingers  behind,  and  he  then  lifts.  In  this  work  the 
outer  ends  of  clavicles  are  elevated  and  thus  the  intra-thoracic 
space  is  augmented.     Pacini  was  led  to  this  procedure  by  observ- 


ARTIFICIAL    RESPIRATIOX.  943 

ing  that  when  the  cadaver  was  thus  carried  iu  the  dissecting 
room,  air  entered  the  lungs  witli  an  audible  sound:  and  this 
escaped  when  the  body  was  put  on  the  table. 

A  plan  similar  to  this  has  been  proposed  by  Bain,  who  places 
the  hand  in  the  armpits  and  uplifts  the  shoulders;  the  difference 
between  this  plan  and  that  of  Pacini  is  that  Bain  fixes  the  hand 
in  the  axilla  from  behind,  while  Pacini  fixes  the  hand  in  front. 

The  methods  of  traction  described  act  through  the  medium  of 
the  arms;  in  1878,  a  plan  was  projDosed  by  Max  Schiiller,  in  which 
the  traction  is  made  at  the  lower  part  of  the  chest.  To  do  this, 
let  the  patient  be  placed  horizontally  on  his  back,  with  a  small 
pillow  under  the  neck.  The  operator  now  stands  or  sits  near  the 
head  of  the  patient,  with  his  back  turned  towards  the  latter;  and 
thus  placed,  he  grasps  the  lower  part  of  the  thorax  on  each  side, 
and,  in  so  doing,  he  insinuates  the  hands  under  the  false  ribs. 
Thus  holding  on  the  lower  costal  arches,  the  operator  pulls 
upwards  and  outwards,  so  as  to  expand  the  chest;  then  he  com- 
presses so  as  to  force  out  the  aspirated  air:  and  in  rhythmical 
succession,  corresponding  to  natural  respiration,  these  movements 
are  continued.  To  aid  in  the  work,  an  assistant  should  lift  up 
the  limbs,  so  as  to  relax  the  abdominal  walls.  Should  the  sub- 
ject lie  on  the  ground,  the  operator  must  kneel  alongside  of  him. 

For  the  revival  of  the  still-born  child  Schultze  has  jDroposed 
a  plan  which  he  names  swinging.  This  consists  in  grasping  the 
lower  limbs  of  the  child  and  alternately  lifting  and  lowering  the 
lower  part  of  the  trunk.  By  the  elevation,  the  abdominal  viscera 
are  made  to  move  against  the  diaphragm,  and  to  narrow  the 
thoracic  space  from  below;  and  when  the  trunk  is  lowered,  this 
space  is  again  enlarged,  and  so,  in  some  degree,  natural  respira- 
tion is  represented. 

Schultze's  method  has  recently  been  criticised,  the  opponents 
claiming  that  by  such  movement  the  abdominal  organs  may  be 
injured.  Thus  Korber,  of  Dorpal,  asserts  that  in  the  work  the 
liver  may  be  lacerated,  vessels  opened,  and  blood  effused.  He 
claims  that  though  the  child  be  born  alive,  yet  it  can  die  through 
such  hEemorrhage.  Such  lesion  appears  in  the  form  of  hepatic 
h^matomata,  which  may  be  inclosed  by  serous  membrane;  blood 
may  actually  be  effused  into  the  abdominal  cavity.  Schultze,  on 
the  contrary,  replies  that  such  rupture  of  the  hepatic  v^essels  is  a 
jDhenomenon  commonly  present  in  the  still-born  child,  and  he 
supports  the  statement  by  reports  of  necropsies  of  still-born  chil- 
dren  which   were   made   by   Pokitansky,   Forster,  and    Weber, 


944  WOUNDS    OF    THE    NECK. 

before  the  swinging  method  was  })racticed.  The  cause  of  such 
lesion  is  to  be  found  in  tlie  conditions  of  the  foetal  circulation  in 
the  asphyxiated  child;  its  lung  not  being  able  to  receive  the  blood, 
the  latter  accumulates  through  the  medium  of  the  umbilical 
vessels  in  the  liver  to  such  an  amount  that  finally  open  rupture 
and  a  hsematoma  may  arise.  Thus  Schultze,  ingeniously  and 
intelligently,  vindicates  his  method.  From  the  discussion  of 
this  plan  by  several  writers  the  inference  may  be  derived  that 
such  swinging  is  improper  in  cases  in  which  the  bones  of  the 
child  have  been  fractured;  also,  if  the  infant  be  a  very  heavy 
one,  the  work  should  be  done  cautiously,  since  in  such  a  child 
lesions  can  more  readily  be  produced.  And  to  practice  this 
work  properly  the  operator  should  previously  make  trial  of  the 
method  on  the  infantile  cadaver. 

Schultze's  method  seems  not  to  have  been  tried  on  the  adult 
and  though  theoretically  it  is  inferior  to  some  of  the  plans  which 
have  been  described,  yet  it  is  evident  that  in  the  alternate  eleva- 
tion and  descent  of  the  lower  part  of  the  trunk,  not  only  is  the 
diaphragm  subjected  to  rhythmical  compression,  but  the  blood  is 
moved  to  and  from  the  brain,  conditions  which  favor  the  reani- 
mation  of  the  subject.  But  since  the  changes  of  dimension  of 
the  intra-thoracic  space  produced  by  such  movements  are  slight, 
in  order  to  accomplish  much,  the  movements  should  be  much 
more  rapid  than  in  normal  breathing. 

Recently  Konig,  of  Gottingen,  has  announced  a  method  of 
resuscitation  by  means  of  manual  compression  over  the  heart, 
and,  while  this  compression  is  being  done,  an  aid  also  compresses 
the  chest.  The  pressure  over  the  heart  forces  the  blood  towards 
the  lungs;  and  such  pressure  should  be  made  on  the  left  costal 
cartilages,  near  the  ensiform  process  of  the  sternum.  Konig 
pressed  from  thirty  to  forty  times  per  minute,  but  his  assistant 
Maas  proposes  to  do  the  work  as  often  as  one  hundred  and  twenty 
times  in  a  minute,  and  to  press  midway  between  the  sternum  and 
the  site  of  the  apex-beat. 

In  1892,  Ivraske  modified  the  plan  of  Silvester  in  this  wise: 
that  after  five  breaths,  during  full  expiration  he  closes  the 
mouth  and  nose  of  the  subject,  and  then  the  arms  are  to  be 
uplifted  in  the  inspiratory  movement.  In  this  way  the  move- 
ment of  the  blood  is  promoted. 

A  verv  simple  ])rocedure  has  recently  been  recommended  as 
a  means  of  resuscitating  the  asphyxiated  subject.  This  is  to  seize 
the   tongue  with  a  pair  of  forceps,  and  to  draw  it  out  of  the 


ARTIFICIAL   RESPIRATION.  945 

mouth  and  then  return  it.  Let  these  movements  be  rapidly  con- 
tinued and  they  will  have  the  effect  to  quickly  awaken  an  inspi- 
ratory act,  as  the  writer  has  verified  on  several  occasions.  This 
extraction  and  retraction  of  the  tongue  should  he  done  simulta- 
neously with  Silvester's  or  Pacini's  resuscitating  protraction  and 
retro-traction  of  the  arms. 

Electrical  excitation  of  the  respiratory  nerves  has  been  pro- 
posed as  a  means  of  resuscitation  by  Ziemssen,  yet  long  before 
the  publication  of  Ziemssen,  electricity  was  used  to  arouse  the 
apparently  dead  subject.  As  a  way  of  applying  it,  one  pole  may 
be  applied  at  the  apex  of  the  heart  and  the  other  on  the  back  of 
the  neck.  The  bold  step  has  been  taken  of  introducing  a  needle 
through  the  thoracic  wall  to  the  heart,  or  even  into  the  cardiac 
wall,  and  then  connecting  this  needle  with  an  electrical  battery. 
Though  the  patient  might  be  revived  by  this  method,  it  would 
be  too  perilous  for  employment,  except  in  cases  which  were 
hopeless,  for  resuscitation  with  a  cardiac  wound,  or  coagulum 
within  the  heart,  would  offer  an  inauspicious  prosjoect  for  the 
patient  even  though  life  v/ere  prolonged. 

Ziemssen's  procedure  consists  in  applying  an  electrode  over 
the  phrenic  nerve  where  it  lies  near  the  middle  of  the  outer  bor- 
der of  the  sterno-cleido-mastoid  muscle,  and  the  other  can  be 
placed  over  the  diaphragm  or  at  the  praecordia,  and  pressed  well 
inwards.  Thus  doing,  the  diaphragm  is  made  to  contract  and 
enlarge  tile  thoracic  space.  The  induced  current  is  employed, 
and  the  current  is  to  be  broken  at  intervals  similar  to  those  in 
normal  respiration.  By  this  procedure  the  alternating  contrac- 
tion and  relaxation  of  the  diaphragm  imitate  that  in  the  mechan- 
ism of  normal  breathing.  Many  years  before  the  announcement 
of  Ziemssen;  the  w^riter,  in  cases  of  interruption  of  breathing,  as 
from  an  anassthetic  or  from  any  other  cause,  employed  electricity 
developed  by  a  Faradic  machine;  and  the  nerves  which  were 
selected  for  excitation  were  the  cardiac  branches  of  the  sympa- 
thetic in  the  neck  and  the  pneumogastric  and  phrenic  nerves. 
To  stimulate  the  sympathetic,  one  electrode  is  to  be  pressed  down 
on  the  structures  which  overlie  the  vasculo-nervous  group  near 
the  cricoid  cartilage;  at  this  point  the  electric  current  will  act  on 
both  the  pneumogastric  and  the  sympathetic  nerves;  and  to  com- 
plete the  chain  of  connection,  the  remaining  pole  should  be 
placed  on  the  left  side  of  the  epigastrium,  close  to  the  heart,  and 
contiguous  to  the  diaphragm.  The  current  should  be  interrupted 
once  in' three  seconds,  so  as  to  imitate  inspiratory  and  expiratory 


940  WOUNDS    OF    TIIK    NKCK. 

action.  The  upper  electrode  may  now  and  then  be  shifted  to  the 
site  over  the  phrenic  nerve.  In  thus  proceeding  one  awakens  a 
triple  innervation,  viz.,  on  the  sympathetic,  pneuraogastric  and 
the  phrenic,  the  effect  of  which  will  be  stimulating  action  on  tlie 
diapliragm  the  heart,  and  the  lungs.  In  the  latter,  through  the 
vagus,  tlie  desire  of  air  (bcsoin  de  rcspirer)  is  awakened. 

If  this  electrization  l)e  continued  for  a  long  period,  the  pro- 
longed contraction  of  the  subjacent  cervical  muscles  will  awaken 
an  inflammation  followed  by  suppuration.  The  writer  has 
observed  this  in  a  patient  who,  from  opiate  narcotism,  was  saved 
from  death  by  respiration  maintained,  by  the  electrical  means 
described,  for  three  hours.  The  violent  irritation  of  the  sterno- 
cleido-mastoid  muscle  during  so  long  a  period  was  followed  by  a 
large  abscess  in  and  around  the  muscle. 

All  methods  having  failed  to  recall  the  patient  to  life,  the  bold 
procedure  proposed  by  Langenbcck  might  be  essayed:  which 
consists  in  making  an  incision  through  the  lower  thoracic  wall  on 
the  left  side  and  near  to  the  ensiform  cartilage.  Through  such 
an  incision,  which  would  pass  to  the  heart  through  the  skin,  the 
attached  margin  of  the  diaphragm  and  the  pericardium,  Langen- 
bcck suggests  that  the  heart  could  be  reached,  grasped  with  the 
hand,  and  compressed  so  as  to  force  the  blood  from  the  organ. 
Before  this  procedure  be  resorted  to,  some  experimentation  should 
be  done  on  the  cadaver  to  determine  how  much  the  general 
circulation  could  be  influenced  by  compressing  the  heart. 
Though  proposed  by  eminent  authority,  it  is  not  probable  that 
this  procedure  will  be  put  into  practice,  unless  in  cases  in  wliich 
apparent  death  actuall}"  touches  on  real  deatli. 

Dvowninrj. — Life  is  sometimes  endangered  or  lost  througli 
partial  or  total  immersion  of  the  body  in  water;  and  in  case  of 
deatli,  the  fatal  ending  is  familiarly  known  as  drowning. 

This  subject  has  been  studied  and  written  on  by  both  the 
pathologist  and  the  humanitarian:  the  former  seeking  to  deter- 
mine how  deatli  thus  arises,  and  the  discoverable  evidences  j^oint- 
ing  to  such  death  ;  the  work  of  the  humanitarian  has  been  chiefly 
directed  to  rescuing  the  partially  drowned.  Medical  writers 
eminent  in  this  field  are  Reaumur,  Louis,  Haller,  Sprengel,  Good- 
win, Fothergill  and  Bert. 

Any  liquid  or  semi-liquid  entering  and  closing  the  air-passages 
can  destroy  life  througli  asphyxiation :  the  blood  not  being  aerated 
in  the  lungs,  life  soon  ceases.  Water  is  usually  the  obstruct- 
ing agent,  yet,  in  a  few  instances,  the  subject  has  been   fatally 


DROWXIXG.  947 

immersed  in  wine.  English  history  records  the  drowning  of  a 
prince  in  a  butt  of  malmsey;  and  the  writer  knew  a  case  of 
drowning  in  a  yat  of  new-made  wine. 

Drowning  may  be  from  mere  immersion  or  partial  immersion 
of  the  head;  yet  ordinarily,  the  entire  body  is  submerged.  The 
act  may  be  voluntary,  accidental  or  homicidal. 

In  more  than  half  of  the  deaths  from  drowning,  Devergie 
claims  that  asphyxia  and  syncope  are  associated  in  the  extinction 
of  life;  and  that  but  one-fourth  die  from  asphyxia  alone,  while 
about  one-eighth  die  from  syncope  and  cerebral  congestion. 

Falk,  Hoffmann,  Bert  and  others  distinguish  three  stages  in 
asphyxiation  caused  by  immersion;  and  this  division  of  the 
subject  has  been  founded  on  experiments  made  on  animals,  and 
on  the  experiences  of  those  who  had  been  partially  drowned, 

1,  The  first  sensation  felt  when  the  head  is  immersed  is  a 
feeling  of  occlusion  of  the  ears  and  a  rushing  sound  in  them;  an 
unpleasant  fullness  in  the  nostrils,  especially  in  the  uj^per  part  of 
them,  and  a  sensation  of  tightness  about  the  chest.  The  immersed 
animal,  and  also  man,  when  unexpectedly  immersed,  inspires  the 
water,  and  then  with  a  strong  exj^iratory  effort,  he  expels  the 
fluid,  along  with  some  of  the  reserved  air  of  the  lungs.  Taylor 
says  that  when  a  person  falls  into  the  water,  and  retains  his  con- 
sciousness, he  at  once  makes  violent  efforts  to  breathe;  this 
applies  to  him  who  is  suddenly  surprised  by  immersion;  he  who 
knows  how  to  swim  will  hold  his  breath  until  he  is  exhausted,or. 
becoming  unconscious,  he  attempts  to  breathe. 

2.  In  the  second  stage,  according  to  Hoffmann,  the  submerged 
subject  makes  deep  and  short  inspirations,  followed  by  expira- 
tions, similar  to  what  occurs  in  other  forms  of  violent  asphyxia 
And  this  stage  ends  in  convulsive  movements  of  the  body.  Bert 
and  others  state  that  the  first  surprise  of  immersion  is  followed 
by  a  calm  in  which  the  subject  makes  no  effort;  then  the  water 
which  has  entered  the  air-passages  excites  movements  of  cough- 
ing; but  between  the  acts  of  coughing,  the  glottis  is  reflexly 
closed,  so  that  nothing  can  enter  it.  Both  the  French  and  Ger- 
man observers  state  that  the  second  stage  ends  in  spasmodic 
movements  and  convulsions. 

Taylor  has  well  described  the  acts  of  the  suddenly  snbmerged 
subject,  who  in  rising  to  the  surface  inspires  air,  but  while  he  does 
so,  since  the  mouth  is  on  a  level  v\dth  the  water,  the  latter  is  also 
drawn  into  the  air-passages;  and  some  is  likewise  swallowed: 
thus  some  of  the  aspirated  water  passes  into  the  lungs,  and  some 


948  WOUNDS    OF    THE    NECK. 

into  the  stomach.  The  struggle  for  life  continues  for  a  longer  or 
shorter  period  of  time,  according  to  the  strength  of  the  subject, 
yet  uliimately  lie  becomes  exhausted,  and  s])eedily  lapses  into 
insensibility;  then  the  body  sinks  so  that  the  mouth  and  nose  are 
quite  underneath  tlie  water;  tlieair  can  no  longer  enter  the  lungs, 
and  a  pari  of  that  wliicli  they  contain,  tlien  escapes,  and  appears 
on  the  surface  of  the  water,  as  bubbles;  and  tlien  the  subject 
becomes  entirely  unconscious. 

3.  In  the  third  stage,  during  which  the  subject  passes  into  a 
condition  of  unconsciousness,  inspiratory  acts  are  made  at  con- 
siderable intervals;  the  mouth  is  widely  open,  the  pupils  dilated 
and  the  muscles  are  convulsed  clonically.  At  last,  the  sphincters 
relax,  and  there  is  absence  of  all  voluntary  or  reflex  movement 
and  death  finally  occurs,  though  the  heart  continues  to  beat  for 
some  time. 

The  time  requisite  to  drown  man  has  been  a  matter  of  differ- 
ence among  writers;  and  those  who  have  ex[)erimented  on  ani- 
mals do  not  agree  as  to  the  time  required  to  destroy  life.  Faure 
hxes  the  time  for  the  animal,  at  one  minute  and  a  half  in  cold 
weather,  and  nearly  twice  that  time  in  warm  weather.  The 
Medico-Chirurgical  Society  of  London,  pronounces  these  figures  to 
be  too  small,  and  fixes  the  time  required  to  drown,  at  from  three 
minutes  and  a  half  to  four  and  two-thirds  minutes.  Taylor 
thinks  that  submersion  during  one  minute  may  so  as])hyxiate  the 
subject  that  he  makes  no  more  efforts  to  escape  from  his  impend- 
ing fote;  and  as  a  rule,  he  thinks  that  a  human  being  who  has 
been  submerged  four  or  five  minutes,  cannot  be  resuscitated. 
Thougli  the  heart  continues  contracting  for  three  or  four  minutes, 
this  is  no  indication  that  the  victim  can  be  revived.  In  the 
annals  of  the  Royal  Humane  Society,  there  are  recorded  but  two 
cases  in  wiiich  life  was  restored  after  submersion  lasting  more 
than  five  minutes. 

Death  has  sometimes  arisen  from  mere  syncope  or  fright 
arising  from  accidental  or  unex])ected  submersion:  and  sucli  a 
subject  makes  no  effort  to  rescue  himself. 

There  are  ca.ses  again,  in  which  the  body  whicli  has  been 
rescued  from  water,  and  which  presented  all  the  signs  of  life, 
nevertheless  died  after  some  hours;  two"  such  ca.ses  are  mentioned 
by  Taylor. 

In  death  from  drowning,  tliebody  presents  diverse  conditions 
depending  on  the  time  which  it  has  remained  submerged. 

Tlie  cadaveric  rigidity  may  be  of  long  or  short  duration;  it 


DROWNING.  949 

is  believed  to  be  brief  in  tliose  who  suddenly  died  from  syncope, 
rather  than  from  prolonged  asphyxia. 

In  death  from  sinking  in  cold  water,  the  skin  is  pale;  but  if 
the  submersion  has  continued  some  hours,  then  the  most  depend- 
ent parts  of  the  body  are  purplish  or  cyanosed,  through  hypo- 
static gravitation  of  the  blood.  And  if  submersion  has  lasted 
many  hours,  the  temperature  of  the  body  will  correspond  with 
that  of  the  containing  medium.  The  action  of  the  cold  on  the 
cutaneous  muscles  causes  the  irregularity  of  the  dermal  surface, 
familiarly  known  as  goose-skin;  and  this  is  thought  to  be  proof 
that  the  subject  has  been  submerged  while  living,  and  not  dead. 

The  attitude  of  the  body  will  furnish  evidence  as  to  whether 
death  was  immediate  from  syncope,  or  after  a  struggle;  in  the 
former,  the  limbs  denote  repose;  but  when  the  subject  endeavored 
voluntarily  or  involuntarily  to  save  himself,  the  limbs  are  in 
constrained  or  unnatural  positions;  the  hand  has  seized,  and  is 
clasping,  some  object,  and  the  face  is  disfigured  by  distortion  of 
the  features,  in  which  fright  and  pain  are  legible.  A  lad  known 
to  the  writer,  who  was  rescued  when  nearly  drowned,  was  found 
by  a  diver  at  the  bottom  of  a  pond  of  water,  clinging  strongly 
to  the  root  of  a  tree. 

Additional  signs  of  death  by  drowning  are  dilated  pupils  and 
foam  in  the  mouth  and  nose;  and  if  the  body  has  remained 
immersed  for  a  long  period,  the  epiderm  is  softened  through 
imbibition  of  water.  But  as  such  epidermal  imbibition  can  occur 
in  the  living  subject,  its  existence  only  denotes  a  prolonged 
immersion  in  water.  Pare'  observed  that  the  skin  of  the  hands 
and  feet  is  often  excoriated,  due  to  movements  against  a  hard 
surface,  during  the  last  struggle. 

In  the  cavity  of  the  mouth  there  is  found  a  quantity  of  foam 
white  or  pink  in  color;  though  this  has  nearly  always  been 
observed  in  the  drowned  man,  it  seems  to  be  absent  in  the 
drowned  animal,  according  to  Montana  and  Bergeron. 

A  condition  to  which  great  importance  is  attached  in  the 
decision  of  the  question  of  death  by  drowning,  is  the  presence  of 
a  quantity  of  white  or  red  foam  in  the  larynx,  trachea  and 
bronchial  tubes.  This  was  seen  in  the  drowned  animal  by 
Morgagni,  Haller  and  other  observers. 

Orfilaand  Piorry  have  not  found  this  foam  in  the  air-passages 
of  those  who,  having  been  wholly  submerged,  remained  so  until 
death ;  subsecjuent  observers  do  not  sustain  Orfila  in  this  state- 
ment: nearly  all  have  found  this  foam  present:  even  in  those  in 


1)50  wor.NDS  OF  Till-:  xkck. . 

whom  death  was  suddenly  induced  by  syncope  after  submersion. 
Should  this  foam  be  absent,  it  could  only  be  exi)licable  by  death 
having  instantly  arisen  from  syncoj^e  uncomplicated  with 
asphyxia.  A\'iien  this  mucus  is  i)i-osent  and  tinted  with  blood, 
the  death  can  be  inl'erred  as  being  preceded  by  a  struggle  of  the 
victim. 

The  lungs  of  tlie  drowned  subject  have  been  carefully 
observed;  and  the  conditions  found  differ.  In  case  the  i)erson 
has  been  submerged  and  died  without  rising  to  respire,  the  lungs 
are  found  in  a  normal  state,  and  similar  to  those  in  whom  the 
death  has  arisen  from  being  buried  under  sand  or  earth.  But  if 
the  victim  has,  in  his  struggles,  risen  and  inspired  air,  then  there 
is  found  a  condition  named  by  Brouardel  and  the  old  observers, 
aqueous  emphysema.  The  pulmonary  tissue  has  lost  its  normal 
elasticity,  and  when  pressed  on,  it  retains  the  imprint  of  the 
fingers.  The  density  of  the  pulmonary  tissue  is  considerably 
augmented.  This  augmentation  hasV)een  pronounced  to  be  three 
or  four  times  that  of  the  normal  density;  yet  later  estimates 
make  this  much  less.  The  lungs  fill  the  thoracic  space  com- 
pletel3^ 

If  the  death  has  been  sudden  and  chiefly  from  syncope,  the 
lungs  will  present  no  exterior  spots  indicative  of  congestion  ;  but 
if  life  has  ended  through  asphyxia,  there  will  be  found  marked 
congestion;  then  the  exterior  surface  will  be  reddish  or  violet,  and 
not  of  uniform  character.  Spots  denoting  ecchymosis  are  visible, 
here  and  there. 

The  congested  pulmonary  tissue  and  the  ecchymosed  spots 
indicate  a  struggle  for  life  on  the  part  of  the  individual,  and 
such  local  marks  are  greater,  the  longer  such  struggle  has  lasted. 
The  lungs  may  present  superficial  em})hysematous  marks.  If 
tlie  pulmonic  parenchyma  be  incised,  there  will  escape  a  foamy 
liquid  tinged  with  blood.  Also,  small  clots  of  blood  from  rup- 
tured capillaries,  are  sometimes  revealed  by  incision. 

The  epithelial  cells  of  the  air-pa.ssages  undergo  alteration  in 
the  drowned  subject,  viz.,  they  are  found  increased  in  size,  and 
their  protoplasmic  content  is  abnormal.  This  change  is  referred 
to  aqueous  imbibition. 

The  blood  of  the  recently  drowned  subject  is  characterized  by 
unusual  fluidity;  but  little  or  no  coagulation  is  found;  if  this 
exists,  it  should  be  discovered  in  the  cardiac  cavities.  This 
liquid  blood  has  l)een  studied,  and  it  lias  been  discovered  that  it 
contains  a  smaller  number  of  red  cells  than  normal  blood.     The 


DROWNING.  951 

blood  of  animals  drowned  experimentally,  and  which  have  strug- 
gled in  the  water  and  inspired  some  air,  is  found  to  contain  fewer 
cells;  the  number  may  be  reduced  one-fourth  or  one-third,  in 
respect  to  the  containing  serum:  that  is,  the  serum  being  increased 
through  the  absorption  of  water,  there  is  an  apparent,  not  real, 
reduction  of  the  red  cells.  Hence  in  the  act  of  drowning,  a 
state  of  hydrsemia  is  induced,  in  subjects  in  whom  much  water 
penetrates  the  air-passages. 

The  general  deduction  from  these  facts  is,  that  when  the  sub- 
ject has  been  suddenly  drowned,  then  clots  may  be  found  in  the 
heart  and  vessels,  and  the  red  cells  exist  in  normal  proportion  to 
the  serum ;  but  if  the  drowning  has  been  prolonged,  then  there 
will  exist  hydraemia,  in  which  the  volume  of  blood  is  augmented 
one-fourth  or  third  above  normal  quantity,  and  it  will  be  liquid; 
and  should  there  be  an  open  wound,  blood  will  continue  to  flow 
from  this  for  some  time;  and  in  the  blood  of  such  subject,  there 
will  be  a  seeming  diminution  of  red  cells. 

That  water,  which  colors  the  air-passages,  can  be  absorbed, 
has  been  experimentally  demonstrated  by  injecting  the  fluid  into 
the  trachea.  The  quantity  which  can  thus  be  absorbed  is  con- 
siderable; but  as  the  animal  resists  the  work  and  expels  some 
which  has  been  introduced,  it  is  inferable  that  in  slow  drowning, 
a  much  larger  quantity  is  absorbed,  and  that  thus  the  hydreemia 
can  be  accounted  for. 

In  the  act  of  drowning,  a  quantity  of  water  is  swallowed;  and 
to  this  Paul  of  iEgina  attributed  death  from  immersion.  This 
was  an  error,  and  the  amount  swallowed  was  overestimated.  In 
experimental  drowning  Brouardel  and  Vibert  found  that  w^hen 
the  oesophagus  of  the  animal  was  ligated,  no  water  was  found  in 
the  stomach;  but  in  those  animals  in  which  the  oesophagus  was 
not  tied,  then  water  was  found  in  the  stomach,  and  the  hydree- 
mia  of  the  blood  was  much  greater  in  the  latter  than  in  those  in 
which  the  oesophagus  had  previously  been  tied:  hence  the  con- 
clusion, that  in  drowning,  the  water  enters  the  blood  both  from 
the  lungs  and  the  stomach;  but  the  greater  part  enters  through 
the  lungs.  The  hydrsjemia  will  be  greater  in  the  case  of  slow 
than  of  sudden  drowning.  The  amount  of  w^ater  found  in  the 
drowned  subject's  stomach  has  been  variously  given;  in  some 
cases  seen  by  Taylor,  none  was  found;  and  Hoffmann  never  saw 
a  large  quantity  in  the  stomach.  Bergeron  and  Montana  state 
that  they  always  found  watei*  in  the  stomach  of  the  drowned:  the 
normal  amount  being  equal  to  a  quart. 


952  WOUNDS    OF    THE    NECK. 

The  question  has  arisen  whether  water  may  penetrate  the 
stoniacli  after  deatli:  a  few  admit  the  possibility  of  this;  the  most 
deny  it. 

The  encephalic  vessels  have  been  found  engorged  in  the 
drowned;  this,  however,  is  not  always  so;  and  when  present,  it  is 
attributed  by  Taylor  to  congestion  of  the  lungs. 

In  his  final  review  of  death  by  submersion,  Laugier,  to  whom 
the  writer  is  indebted  for  much  that  has  here  been  presented, 
says  that  the  individual  may  die  in  diiferent  ways:  he  may  die 
suddenly  from  syncope  and  cerebral  congestion;  or  in  so  brief  a 
time,  that  there  may  be  no  struggle.  And  in  such  cases,  the 
concu.ssion  from  the  fall,  the  coldness  of  the  water,  the  startling 
fright,  or  drunkenness,  may  be,  singly  or  combined,  agencies  of 
syncope,  or  cerebral  congestion.  Or  death  ma}^  result  from 
asphyxia  after  a  long  struggle  for  life;  and  then  tlie  asphyxia  is 
not  due  to  swallowed  water,  as  Paul  of  ^Egina  thought;  nor  the 
collection  of  blood  in  the  right  ventricle  of  the  lieart  through 
pulmonary  inaction,  as  Coleman  and  Sprengel  believed;  nor 
from  apoplexy  caused  by  respiratory  obstruction,  as  taught  by 
Littre  and  Boerhaave;  nor  from  the  occlusion  of  the  glottis  pre- 
venting the  entrance  of  air,  as  Beau  claims;  nor  from  the  vitia- 
tion of  the  blood  due  to  lack  of  contact  with  pure  air.  as  believed 
by  Orfila;  but  death  is  caused  by  the  penetration  of  water  into 
the  pulmonary  pa.ssages.  That  life  is  thus  destroyed  in  drown- 
ing has  been  demonstrated  by  careful  and  judicious  experimen- 
tation by  Paul  Bert,  Riedell,  Bergeron,  Montana.  Brouardel  and 
Yibert. 

The  suction  of  water  into  the  air-passages  which  occurs  in  the 
first  stage,  when  the  subject  is  surprised  by  immersion  under 
water,  becomes  much  greater  in  the  third  stage  when  asphyxia 
has  commenced;  then,  according  as  Bert  has  noticed,  the  water 
is  drawn  into  the  lungs  by  deep  inspirations  automatically  pro- 
duced :  the  mere  continuance  of  the  accustomed  habit  of  breath- 
ing. And  these  movements  are  so  strong  that  the  water  is  drawn 
into  the  deepest  portions  of  the  lungs  and  there  reaches  the  ulti- 
mate vesicles;  then  the  unconscious  patient,  with  the  desire  for 
air  instinctivel}'  remaining,  breathes  the  w^atery  medium  instead 
of  air.  And  the  water  being  abundantly  introduced  into  the 
lungs,  hydrsemia  is  induced  through  its  absorption;  and  thence 
is  formed  that  foamy  liquid  which  is  discovered  in  all  parts  of  the 
air-passages,  and  also,  in  the  pharynx  and  buccal  cavity.  The 
aqueous  transudation  in  the  finer  vessels  produces  changes  in 


DROWNING. 


953 


the  protoplasmic  content  of  the  epithelial  investment  of  the  finer 
tubes. 

Death  may  come  from  immediate  suffocation;  or  it  may  come 
after  the  subject  has  been  rescued  yet  alive  from  the  water,  at  a 
later  period,  varying  from  minutes  to  hours  or  days ;  and  some- 
times, death  occurs  because  the  nearly  dead  lungs  cannot  expel 
the  admitted  water;  or  the  epithelial  lining  of  the  tubules  and 
vesicles  has  been  so  changed,  and  is  so  degenerated  through 
aqueous  imbibition,  that  the  oxidation  and  decarbonization  of 
the  blood  are  imperfectly  accomplished.  If  enough  water  has 
not  entered  to  produce  these  effects,  then  resuscitation  is  pos- 
sible. 

Many  means  have  been  resorted  to  to  revive  the  partly 
drowned  patient ;  and  among  these,  that  of  removing  the  water 
which  had  been  swallowed  was  one  of  the  most  popular:  since 
from  antiquit}^  the  notion  was  current  that  the  swallowed  water 
was  the  prime  cause  of  death.  As  a  rude  way  of  accomplishing 
this  regurgitation,  the  patient  was  suspended  by  his  feet.  Intel- 
ligent medical  men  long  ago  decried  this  procedure;  among 
whom  may  be  mentioned  Plater  in  the  sixteenth  century,  who  in 
a  pithy  comment  on  the  plan,  said  that  in  suspension,  more  water 
flowed  from  the  subject's  clothing  than  from  his  mouth.  And 
yet,  to-day,  among  sailors,  as  soon  as  the  submerged  victim  has 
been  rescued  from  the  water,  the  first  cry  is  to  "roll  him;  "  and 
quickly  "suiting  the  action  to  the  word,"  the  unfortunate  one  is 
rudely,  and  often  violently,  rolled  to  and  fro,  with  the  result  that 
his  body  is  more  bruised  than  emptied  of  its  water.  Intelligent 
resuscitation  has  long  since  dropped  from  its  methods  vertical 
suspension  and  horizontal  rolling. 

Subsequently,  the  theory  of  Littre  and  Boerhaave,  that  death 
from  drowning  arises  from  cerebral  apoplexy,  led  to  withdrawal 
of  blood  by  bleeding;  and  this  was  deemed  to  be  most  effective 
when  the  bleeding  was  done  from  the  jugular  vein. 

Finally,  when  the  cause  of  death  had  been  solved  by  observa- 
tion and  experimentation,  the  methods  of  revival  reduced  them- 
selves to  two  classes  of  management :  one,  in  which  general  and 
local  excitation  of  the  body  is  resorted  to  ;  and  the  other  method, 
in  which  are  comprised  the  different  means  of  artificial  respi- 
ration. 

Among  the  means  of  excitation,  which  fall  under  the  first 
head,  a  popular  one  is  the  application  of  heat  to  the  patient;  this 
has  been  recommended  by  Tissot,  Fothergill  and  others.  Heat 
61 


954  WOUNDS    OF    THE    NECK. 

may  be  applied  in  the  form  of  warm  water,  warm  sand,  a  warn, 
plate  from  a  stove,  or  any  warm  object  which  is  accessible  and 
applicable.  Warm  embrocations  may  be  applied,  consisting'  of 
flannels  which  have  been  dipped  in  hot  water,  and  on  which 
alcohol  or  turpentine  has  been  sprinkled.  Such  excitant  warnitli 
may  be  a])plied  to  all  parts  of  the  body;  it  is  best  done,  however, 
over  the  heart  and  lungs,  since  the  chief  aim  is  to  awaken  the 
functions  of  these  organs.  Friction  with  the  palm  of  the  hands 
may  be  done.  Another  excitant  is  electricity;  also  thermal  cau- 
terization of  the  limbs  and  prsecordia.  The  tickling  of  the 
nostrils  is  an  efficient  means  of  awakening  a  reflex  action,  in 
which  the  diaphragm  will  be  made  to  contract  in  acts  of  cough- 
ing and  sneezing.  Also  titillating  the  pharynx  awakens  reflex 
actions  of  a  respiratory  character.  And  akin  to  this,  as  coun- 
seled by  Heister  and  Desgranges,  is  the  passage  to  the  stomach 
of  a  tube  or  tampon,  armed  with  a  brush,  with  which  friction  can 
be  made.  Volatile  stimulants  may  be  introduced  into  the  mouth 
and  nostrils;  and  one  usuall}'  at  hand,  is  camphor  spirit;  and 
another  yet  more  energetic  is  spirit  of  ammonia,  of  which  the 
escaping  fumes  will  excite  the  respiratory  mucous  membrane. 
The  parenchymatous  injection  of  alcohol  may  be  done,  and  to 
hasten  absorption,  the  penetrated  structures  should  be  well 
rubbed;  thus  the  alcohol  is  made  to  enter  the  vessels,  and  its 
general  action  is  hastened;  and,  at  the  same  time,  the  friction 
diminishes  the  tendency  to  local  irritation  of  the  injected  tissues. 
Strychnia  may  also  be  hypodermically  used.  These  means  are 
applicable  in  those  cases  in  which  apparent  death  has  arisen 
from  syncope,  rather  than  from  asphyxia;  in  all  such  the  local 
excitants  should  be  sedulously  plied. 

In  case  apparent  death  is  from  asphyxia,  the  jaws  are  some- 
times found  tightly  clenched,  and  must  be  forcibly  opened  by 
means  of  some  wedge-shaped  object,  or  other  divulsive  instru- 
ment. And  then  through  an  aspirating  tube  wljich  has  been 
introduced  into  the  throat,  foam}^  material  which  has  lodged 
there  may  be  aspirated. 

In  addition  to  the  use  of  the  local  and  general  excitant  means 
which  have  been  enumerated,  there  should  be  an  immediate 
resort  to  artificial  respiration;  and  of  the  methods  before 
described,  the  author  recommends  that  of  Silvester  as  the  most 
trustworthy;  and  this  should  diligently  be  proceeded  with,  while 
the  local  remedies  are  being  used. 

As  a  prelude  to  Silvester's  method,  which  has  already  been 


FOREIGN    BODIES    IX    THE    AIR-PASSAGES.  955 

described,  the  subject's  mouth  and  pharynx  should  be  wiped  out; 
and  during  the  traction  and  retro-traction  of  the  arms,  the 
tongue  should  be  drawn  well  forwards,  and  held  in  this  position. 
And  along  with  this  work,  rapid  pressure,  done  intermittently, 
should  be  made  on  the  left  side  of  the  thorax,  near  the  ensiform 
cartilage. 

The  length  of  time  necessary  to  destroy  the  human  subject 
by  submersion  is  probably  about  five  minutes;  yet  numerous 
cases  are  on  record,  in  which  resuscitation  occurred  after  a  much 
longer  period.  For  example :  the  Royal  Humane  Society  of 
London  mentions  return  to  life  after  submersion  for  forty 
minutes.  The  memoirs  of  the  Society  of  Amsterdam  mention 
cases  of  rescue  after  the  subject  had  been  three-quarters  of  an 
hour  under  water.  Franck  has  recorded  a  case  which  outstrips 
the  record  of  his  predecessors,  viz.,  life  was  saved  after  three 
hours'  immersion. 

Tliough  these  statements  of  the  historians  of  submersion  are 
probably  exaggerations,  yet  they  justify  the  resuscitator  in  his 
efforts,  and  to  err  rather  on  the  side  of  prolonged  than  of  cur- 
tailed perseverance,  in  his  liumane  work. 

Foreign  Bodies  in  the  Air-passages. — Foreign  bodies  of  the 
most  diversified  character  have  entered  the  air-passages,  and 
finding  temporary  or  prolonged  lodgment  there,  have  imperiled 
or  destroyed  the  life  of  the  subject.  Such  body,  if  of  inorganic 
composition,  may  remain  unchanged  in  its  volume,  being 
neither  lessened  nor  augmented ;  but  if  it  be  of  organized  material, 
it  may  increase  in  size,  or  lessen  through  solution  or  disintegra- 
tion ;  an  example  of  the  inorganic  is  a  bead,  a  shot  or  coin,  while 
of  the  organic  class,  fragments  of  food,  the  pea,  bean,  grain  of 
corn,  are  familiar  examples.  "Within  the  writer's  observation, 
the  bean  and  grain  of  corn  have  caused  the  greatest  number  of 
accidents  of  this  kind. 

Several  writers  have  contributed  to  the  literature  of  this  sub- 
ject; prominent  among  them  have  been  Jobert  de  Lamballe,  S.  D. 
Gross  and  Chassaignac. 

Jobert  de  Lamballe,  writing  in  1850,  states  that  the  foreign 
body  usually  enters  the  right  bronchus.  The  weight  of  the  body 
and  the  suction  to  which  it  is  subjected  carry  it  into  the  air- 
passages.  The  uplifting  of  tlie  epiglottis  is  not  necessary,  since 
this  valve  never  lies  downwards  and  backwards,  but  its  position 
is  such  as  to  form  a  kind  of  a  guiding  or  conducting  sulcus, 
along  which  passes  any  material  which  traverses  the  pliarynx. 


956  WOUNDS   OF    THE   NECK. 

The  entrance  of  the  body  is  indicated  by  disturbed  breathing, 
cough,  constant  or  intermittent  pain,  and  bronchial  discharge, 
which  is  often  tinged  with  blood.  A  peculiar  rhoncus  is  lieard, 
and  the  breathing  is  louder  on  the  side  which  the  body  did  not 
enter.  A  large  body  can  cause  immediate  death  througli 
asphyxia,  but  a  smaller  body  acts  more  slowly^  namely:  it  causes 
suppuration,  eni})hysema  and  progressive  asphyxia.  If  the  body 
exceeds  four  lines  in  diameter,  it  cannot  be  expelled  by  coughing; 
yet  when  less  than  four  lines,  there  is  a  chance  that  the  bod}' 
may  escape.  Jobert  advises  the  early  performance  of  tracheot- 
omy; and  then,  to  facilitate  the  exit  of  the  body,  he  tickles  the 
mucous  membrane  of  the  trachea  to  provoke  expulsive  cough- 
ing; and  when  thus  the  body  has  escaped,  close  the  wound  with 
sutures  which  do  not  enter  too  deeply.  In  case  the  body  is  not 
at  once  dislodged,  then  the  wound  must  be  retained  open. 

In  1854,  S.  D.  Gross  wrote  an  elaborate  monograph  on  foreign 
bodies  in  the  air-passages;  and  the  materials  for  this  work  were 
derived  from  personal  observations  ^nd  from  published  records, 
amounting  to  about  250  cases. 

From  an  analytical  study  of  these  cases,  he  deduces  the  follow- 
ing facts:  the  body  may  remain  in  the  larynx  or  descend  into 
the  bronchial  division  of  the  trachea;  and  then  it  usually  lodges 
in  the  right  bronclius.  The  form  and  weight  of  the  body  often 
determine  tlie  point  of  lodgment.  A  small,  round  and  lieavy 
body,  as  a  bean,  shot,  or  gravel,  etc.,  descends  more  easily  into 
the  passages  than  a  light,  rough,  or  angular  one.  The  body  often 
changes  position,  passing  from  one  bronchus  to  the  other,  or 
into  the  trachea  or  larynx. 

As  soon  as  a  body  has  entered  the  air-passages  there  is  an 
irresistible  desire  to  cough,  and  a  feeling  of  impending  suffoca- 
tion; the  face  is  livid,  and  the  patient  may  fall  into  a  state  of 
unconsciousness.  After  some  time  the  violence  of  these  symp- 
toms subsides  and  remains  so  for  some  minutes.  If  the  body  has 
entered  the  larjmx,  the  voice  is  altered,  and  there  is  commonly 
present  a  croup-like  cough,  and  the  resonance  of  air  entering  the 
lungs  is  diminished.  In  case  the  body  is  not  fixed  but  is  floating 
in  the  larynx,  then  tlie  spasms  of  cough  often  recur,  as  if  tlie 
body  had  only  just  entered.  Such  movement  of  the  body  can 
be  felt  by  the  patient,  though  it  may  be  imperceptible  to  the 
examining  physician.  A  large  body  has  so  completely  filled  a 
bronchus,  that  the  corresponding  lung  collapsed.  And  in  some 
cases,  the  site  of  the  lodged  body  is  indicated  by  a  fixed  local 
pain. 


FOREIGN   BODIES   IN   THE   AIR-PASSAGES.  957 

The  body  can  destroy  life  at  once,  or  at  a  later  period ;  and 
the  dangers  of  sudden  death  are  greater  when  the  body  can  move 
to  and  fro,  and  become  engaged  in  the  glottis.  If  it  lodge  in  the 
lungs  a  fatal  inflammation  may  arise  from  it.  If  the  body  be 
caught  in  one  of  the  ventricles  of  the  larynx,  it  causes  less 
trouble  than  anywhere  else;  yet  in  some  cases,  though  the  body 
was  lodged  in  the  larynx,  it  caused  a  dangerous  inflammation. 

As  treatment,  Gross  discards  errhines,  vomiting,  inversion  of 
the  body,  striking  and  shaking  the  thorax;  but  he  depends  wholly 
on  tracheotomy,  or  laryngotomy;  the  latter  is  only  to  be  done 
when  the  body  is  in  the  larynx.  The  opening  should  be  one 
inch  long  in  the  child,  and  one  inch  and  a  quarter  in  the  adult. 
And  when  the  body  is  not  found,  or  at  once  expelled  through  the 
opening,  then  invert  the  patient,  shake  and  strike  the  chest;  and 
these  acts  failing,  then  retain  the  gap  open  by  means  of  retractors. 
And  whether  the  body  escapes  early  or  later,  close  the  wound  as 
soon  as  the  former  has  made  its  exit. 

Kapesser  of  Giessen  observed  thirty-two  cases  in  which  bodies 
had  entered  the  air-passages;  tracheotomy  was  done  in  all,  and 
in  the  greater  number  tlie  patient  was  rescued  at  once;  in  three, 
the  body  was  coughed  up  at  a  later  period ;  and  in  one  case,  the 
patient  was  lost  from  bleeding  during  the  operation.  If  the 
body  is  lodged  in  the  upper  portion  of  the  windpipe,  it  causes  less 
irritation  there  than  if  it  be  lower  down,  since,  as  Erichsen  has 
observed,  the  mucous  membrane  is  less  irritable  in  the  upper 
part  of  the  trachea. 

As  a  rule,  the  body  lodges  in  the  right  bronchus;  yet  in  one 
necropsy,  Ortli  found  it  in  the  left  bronchus. 

In  the  case  of  the  entrance  of  a  foreign  body  into  the  wind- 
pipe, Chassaignac  advises  an  immediate  operation;  and  in  the 
event  of  the  body  being  felt,  he  cuts  directly  down  on  it;  other- 
wise, Chassaignac  performs  the  usual  operation  of  tracheotomy. 

The  writer  has  had  personal  observation  of  five  cases  in  which 
foreign  bodies  had  entered  the  windpipe.  The  object  in  one  case 
was  a  small  cylindrical  hollow  metallic  body,  which  was  a  line  in 
diameter  and  three  lines  in  length;  the  second  was  a  grain  of 
Indian  corn;  and  in  the  other  three  the  object  was  a  bean. 

In  four  of  these  cases,  tracheotomy  was  done;  in  the  one 
unoperated  upon,  the  child  died  of  pulmonary  disease  three  weeks 
after  the  body  was  inhaled;  on  post-mortem  examination,  a 
grain  of  corn  was  found  in  the  right  bronchus.  In  the  child 
which  had  mis-swallowed  the  metallic  cylinder,  tracheotomy  was 


958  WOUNDS   OF  ,THE    NECK. 

<lone,  and  the  object  found  in  the  upper  part  of  the  hirynx. 
When  the  traeliea  was  opened,  a  flexible  catheter  was  passed  into 
the  wound,  and  the  body  pushed  upwards  into  the  pharynx,  and 
caught  there.  In  another  child  in  which  the  object  was  a  bean, 
ihe  object  was  not  discharged  at  once  through  the  tracheal  open- 
ing; but  the  wound  being  retained  open,  tlie  body  was  expelled 
one  vv^eek  afterwards,  and  the  child  recovered.  And  in  the 
remaining  two,  though  tracheotomy  was  done,  yet  the  body 
remained  lodged  in  a  bronchus,  and  the  children  died  of  pulmo- 
nary inflammation. 

In  those  cases  in  which  the  body  remained  impacted  deeply 
in  a  lung,  there  was  only  occasional  coughing  ;  the  predominant 
symptom  was  accelerated  breathing,  with  lessened  respiratory 
murmur  on  one  side,  and  increased  or  puerile  breathing  on  the 
other  side.  And  in  the  case  in  which  a  grain  of  corn  was  the 
obstructing  agent,  so  long  were  the  intervals  between  the  parox- 
ysms of  coughing,  that  it  seemed  scarcely  probable  that  they 
could  arise  from  the  presence  of  a  foreign  body.  It  would  appear, 
then,  that  the  longer  the  body  remains  in  the  bronchial  tube,  the 
less  irritation  does  it  cause:  that  is,  the  most  marked  and  mislead- 
ing condition  in  such  cases  is,  that  long  lodgment  of  such  body 
gives  tolerance,  and  finally  nullifies  the  reflex  action  of  the  local 
irritant. 


CHAPTER  XXIX. 


CESOPHAGUS. 


The  name  cesophagus  is  derived  from  the  Greek  words  oisein. 
to  be  about  to  carry  or  bring;  smd  2)hagein,  to  eat.  The  word  is 
used  by  Hippocrates  and  Aristotle  to  indicate  the  gullet;  but 
later  Greek  writers  employed  the  word  stomachos  as  name  for 
this  part.  Even  Vesalius  used  the  latter  name.  This  confusion  of 
terms  may  have  arisen  from  the  equivocal  passage  in  Hippocrates' 
short  chapters  on  the  anatomy  of  the  trunk;  he  says  there  that 
the  cesophagus  takes  its  beginning  from  the  stomach,  and  ends 
in  a  hollow  space;  and  the  former,  on  account  of  being  a  great 
mouth  (stoma)  to  this  digesting  cavity,  is  named  stomach.  In  tlius 
paraphrasing  the  Hippocratic  text  the  latter  has  not  been  greatly 
elucidated  by  the  license  taken  by  the  translator. 

The  oesojDhagus  is  a  canal  of  variable  calibre,  which,  according 
to  Henle,  begins  at  the  lower  border  of  the  cricoid  cartilage,  or  at 
the  union  of  the  sixth  and  seventh  cervical  vertebrse,  and  reaches 
thence  downwards  to  the  diaphragm,  through  which  it  passes  to 
the  stomach,  into  which  it  opens  at  a  point  corresponding  to  the 
body  of  the  eleventh  thoracic  vertebra.  Its  beginning  is  some- 
what indefinite;  but  it  properly  commences  where  the  circular 
muscular  fibres  appear  below  the  constrictor  pharyngis  inferior. 
AVhile  the  pharynx  has  muscular  attachment  to  the  cranium, 
lower  jaw  and  hyoid  bone,  the  cesophagus  has  only  very  loose 
adherence  to  contiguous  parts;  the  tube  severed  from  the  inferior 
border  of  the  pharynx  can  easily  be  detached  from  the  parts 
around. 

The  oesophagus,  except  when  dilated  by  materials  which  have 
been  swallowed,  or  those  which  regurgitate  from  the  stomach,  is 
closed,  and  is  similar  to  a  flat  cylindrical  cord,  due  to  the  contrac- 
tion of  the  muscular  walls;  and  the  inner  mucous  wall  is  disposed 
in  longitudinal  folds,  so  that  if  a  section  of  it  be  made  it  has 
a  radiated  appearance.  The  contracted  ossophagus  measures  in 
diameter  nearly  a  half  inch. 

( 959  ) 


960  cesophaGus. 

Mouton  has  measured  the  calibre  of  the  distended  oesophagus, 
by  filling  it  witii  gypsum,  when  he  found  the  diameter  to  be,  at 
the  beginning,  three-quarters  of  an  inch;  at  the  middle,  an  inch 
and  a  half;  and  at  the  lower  end,  nearly  an  inch.  From  its 
varying  diameter,  the  oesophageal  tube  has  been  compared  to  the 
male  urethra,  which  is  narrower  at  its  ends  than  at  its  middle. 

If  the  distance  be  measured  from  the  incisor  teeth  to  the  point 
where  the  oesophagus  ends  in  the  stomach,  it  is,  on  an  average, 
seventeen  inches  long;  and  five-eighths  of  this  pertains  to  the 
oesophagus;  and  the  latter  consists,  according  to  situation,  of  a 
cervical,  thoracic  and  abdominal  portion.  The  upper  portion  of 
the  oesophagus  lies  between  tlie  trachea  and  the  spinal  column; 
and  at  its  entrance  into  the  thorax,  it  deviates  towards  the  left 
side;  then  it  returns  to  its  median  situation  again  ;  and  commonly, 
in  consequence  of  the  trachea  deviating  towards  the  right,  when 
the  oesophagus  readies  the  point  where  the  trachea  bifurcates,  the 
former  is  situated  behind  the  left  bronchus.  Lower  down,  the 
("esophagus  lies  behind  the  pericardium,  and  it  is  attached  to  the 
latter;  and  thence  downwards  it  is  preseed  away  from  the  spinal 
column  by  the  aorta  and  the  vena  azygos,  and  when  it  reaches 
the  lower  edge  of  the  left  fourth  costal  cartilage,  it  lies  nearly  in 
front  of  the  thoracic  aorta.  Its  connection  with  parts  around  is 
through  the  medium  of  an  extremely  elastic  tissue. 

The  wall  of  the  undistended  oesophagus  is  one  line  thick,  and 
three-fourths  of  this  is  of  muscular  tissue:  the  inner  lining  being 
mucous  membrane. 

The  muscular  wall  consists  of  longitudinal  and  circular 
fibres.  The  longitudinal  fibres  lie  external,  and  arise  above  by 
three  sections :  two  lateral  and  a  median.  The  lateral  portions 
start  from  the  elastic  structure  in  which  the  palato-pharyngeal 
muscles  end;  while  the  middle  portion  springs  from  the  posterior 
part  of  the  cricoid  cartilage,  through  the  medium  of  a  three-sided 
elastic  membrane.  The  circular  muscular  coat  lies  internal  to  the 
longitudinal  fibres;  and  both  the  longitudinal  and  circular  fibres 
})ertain  to  the  striated  species,  in  the  U[)per  fourth  or  third  of  the 
canal;  below  that  distance,  the  non-striped,  or  organic  species  of 
fibre,  replaces  the  former;  this  change  occurs  where  the  cervical 
portion  reaches  and  enters  the  thorax. 

As  before  stated,  the  pharyngeal  portion  of  the  alimentary 
canal  is  formed  and  supported  by  muscles  which  have  bon}'  ori- 
gin; somewhat  analogous  are  the  miniature  muscles  whicli  con- 
nect the  oesophagus  to  contiguous  structures.     Thus  Hyrtl  has 


CONGENITAL    DEFECTS    OF    THE    iESOPPIAGUS.  961 

described  the  broncbo-oesopbageus  and  tbe  pleuro-oesopbageus 
muscles.  Muscular  slips  bave  been  described  which  connect  the 
oesophagus  with  the  pericardium  and  aorta.  These  muscles, 
which  are  of  organic  species,  serve  the  purpose  of  maintaining 
the  tube  straight ;  and  according  to  Henle,  they  screen  adjacent 
vessels  from  compression.  These  muscles,  also,  are  the  means  of 
attaching  the  oesophagus  to  the  diaphragm. 

The  oesophagus  receives  its  supply  of  blood  from  the  inferior 
thyroid,  oesophageal  and  phrenic  arteries.  The  veins  below  empty 
into  the  portal  system:  and  from  this  connection,  these  veins 
become  swollen  in  cases  of  cirrhosis  of  the  liver. 

The  innervation  of  the  oesophagus  is  through  the  medium  of 
the  vagus;  and  this  nerve  has  its  nuclear  origin  in  the  medulla- 
oblongata.  The  branches  of  the  vagus,  which  are  chiefly  con- 
cerned in.  this  involuntary  innervation,  are  the  superior  and 
inferior  laryngeal  nerves;  other  branches,  when  experimentally 
stimulated,  have  been  found  without  action. 

Some  interesting  vivisective  work  on  the  oesophagus  has  been 
done  by  Angelo  Mosso,  who  found  that  an  impression,  made  on 
the  mucous  membrane  in  the  upper  part  of  the  oesophagus,  trav- 
eled gradually  downwards  in  a  peristaltic  manner;  and  what  was 
most  remarkable,  this  movement  continued,  even  though  the 
oesophageal  tube  were  divided  into  two  parts.  The  excitant  irri- 
tation which  awakened  this  movement  lost  its  effect,  if  repeated 
too  often. 

Congenital  Dejects  of  the  Oesophagus. — The  oesophagus  some- 
times presents  congenital  defects  which  are  explicable  through 
an  arrest  of  growth  during  the  period  of  embryonic  evolution. 

In  the  development  of  the  embryo,  the  alimentary  canal  con- 
sists of  an  anterior,  middle  and  a  terminal  portion ;  and  of  these, 
the  anterior  becomes  the  pharynx  and  oesophagus;  and  cotem- 
poraneously  with  this,  the  trachea  and  lungs  are  developed.  At 
an  early  period,  the  tracheal  and  oesophageal  structures  form  a 
common  canal  which  opens  into  a  hollow  below,  from  which 
hollow  the  lungs  are  formed.  As  growth  proceeds,  a  partition 
develops  and  separates  the  common  tube  into  an  anterior  one, 
the  treachea,  and  a  posterior  one,  the  oesophagus.  But  from 
some  unknown  cause,  this  differentiation  of  parts  may  take  an 
abnormal  course,  and  defects  arise.  Thus,  instead  of  a  continu- 
ous canal,  the  oesophagus  may  abruptly  terminate  in  a  blind 
sack;  or  the  oesophagus  may  open  into  the  trachea,  or  into  a 
bronchus;  or  there  may  be  a  combination  of  defects,  in  which 


962  (ESOPHAGUS. 

there  is  abnormal  ending,  as  well  as  interruption  and  closure  of 
the  canal.  And  finally,  the  oesophagus  may  be  reduced  to  a 
cord-like  structure,  throughout  a  part  or  the  entirety  of  its  length. 

Examples  ilhistrating  congenital  oesophageal  defect  are  the 
following,  collected  by  Luton,  A  new-born  child  died  on  the 
fourth  day,  and  on  necropsy  it  was  found  that  the  oesophagus 
ended  blindly  near  tiie  tracheal  bifurcation,  and  a  ligamentous 
structure  seemed  to  continue  to  tlie  stomach.  In  another  infant, 
the  examination  revealed  the  ftict  tliat  the  upper  part  of  the 
oesophagus  ended  blindly  at  the  middle  of  the  canal;  the  part 
below  opened  into  the  trachea.  In  another  child  which  died  on 
tlie  seventh  day,  there  was  found  an  absence  of  the  oesophageal 
tube;  and  the  stomach  contained  no  cardiac  orifice.  In  another 
infant,  which  died  on  the  eleventh  day,  the  oesophagus  ended  in 
a  cul-de-sac  an  inch  below  the  pharynx;  the  inferior  end  opened 
into  the  trachea  above,  and  into  the  stomach  below,  so  that  fluid 
from  the  stomach  regurgitated  through  the  trachea;  and  the 
blind  portion  and  the  lower  portion  were  connected  by  an  im- 
perforate cord.  In  another  infant  which  died  on  the  fifth  day, 
there  was  closure  found  in  the  oesophagus  two  inches  below  its 
origin;  the  inferior  section  opened  into  the  trachea  on  the  pos- 
terior face  of  the  latter.  In  another  case,  there  was  found  clo- 
sure of  the  oesophagus  nearly  two  inches  above  the  tracheal  bifur- 
cation; and  thence  downward  the  oesophagus  was  found  obliter- 
ated to  a  cord,  which  pierced  the  diaphragm  to  reach  the  stomach; 
and  the  oesophagus  communicated  with  the  trachea,  in  this  case. 
In  another  infant  the  pharynx  was  closed,  and  there  existed  a 
tracheo-cesophageal  fistula ;  and  with  these  defects  coexisted  im- 
perforate anus,  club-foot,  hare-lip,  deformity  of  the  fingers,  and 
absence  of  the  genital  organs.  In  another  infant,  in  which  the 
universality  of  deformity  rendered  the  child's  body  a  miniature 
museum  of  teratology,  the  normal  oesophagus  was  lacking,  and, 
in  its  stead,  the  trachea  consisted  of  two  tube-like  portions,  of 
which  one  passed  to  the  stomach  and  the  other  to  the  lungs. 

Hence,  as  seen,  the  congenital  defects  of  the  oesophagus  offer 
much  diversity  of  form;  in  most  cases  the  tube  opens  into,  or 
communicates  with,  the  trachea  or  a  bronchus;  and  in  a  few 
infants  the  oesophagus  is  reduced  to  an  impermeable  cord.  In 
both  conditions  life  cannot  continue,  for  in  all  the  nutriment 
cannot  properly  reach  the  stomach;  and  in  some  starvation  and 
asphyxia  unite  in  the  destruction  of  the  victim. 

Surgery  seems  to  have  seldom  intervened  to  lend  assistance 


STRICTURE    OF    THE    ESOPHAGUS.  963 

to  such  unfortunates;  they  have  been  permitted  to  perish  by 
inanition,  death  occurring  in  from  five  to  ten  days,  life  usually 
ending  within  a  week.  Yet  in  this  era,  when  operative  surgery 
has  accomplished  so  much  in  restitution  to  continuity  of  the 
intestinal  tube,  when  occluded  by  neoplasm  or  other  agency, 
would  it  not  be  well  to  make  some  essays  in  this  unexplored 
field,  which  patiently  awaits  the  advent  of  operative  effort? 
While  every  cubic  inch  of  the  intra-abdominal  space  bristles 
with  edomies,  otomies  and  ostomies,  why  not  open  the  neck  of  the 
new-born  infant,  and  seek  for  the  deformed  oesojihagus,  and, 
where  viability  is  but  slightly  interrupted,  restore  permeability 
by  some  procedure  suggested  by  operations  done  on  the  intestine 
and  urethra?  By  such  operative  eff'ort,  let  it  be  never  so  hazar- 
dous, there  could  not  be  added  one  unit  to,  but  possibly  one 
might  be  subtracted  from,  the  chances  of  death  which  otherwise 
overhang  the  life  of  the  little  patient. 

Stricture  of  the  OEsophagus. — Stricture  figures  in  many  affec- 
tions of  the  oesophagus;  it  is  the  causal  agency  of  disphagia,  or 
difficulty  of  swallowing. 

From  complete  closure  occurring  in  the  new-born,  the  transi- 
tion is  easy  to  incomplete  closure,  which  has  been  observed  in  the 
infant:  a  case  was  reported  in  1833,  by  iEger.  Should  such 
defect  be  discovered,  the  appropriate  treatment  would  be  gradual 
dilatation  by  means  of  graduated  sounds. 

Of  causal  agencies  whence  stricture  may  originate  a  frequent 
one  is  the  destruction  of  the  inner  surface  by  caustic  action,  which 
may  be  from  a  heated  fluid  or  an  escharotic;  thence  may  arise 
gradual  cicatricial  closure. 

Steiger,  of  Wlirzburg,  in  1861,  wrote  on  oesophageal  stricture, 
and  he  claimed  that  the  only  certain  means  of  diagnosing  it  is 
the  use  of  the  sound:  this  meeting  an  obstacle  indicates  stricture. 
Additional  signs  of  such  stricture  are  difficulty  of  swallowing, 
which  commonly  comes  on  imperceptibly.  The  trouble  in  deglu- 
tition is  not  always  proportioned  to  the  narrowing,  since  some- 
times there  is  much  difficulty  when  the  stenosis  is  slight.  In 
case  the  stricture  be  low  down,  the  patient  locates  the  trouble  in 
the  stomach.  The  symptom  which  usually  first  attracts  the 
patient's  attention  is  vomiting  or  a  tendency  to  vomit.  The 
vomiting  may  not  be  constant,  but  it  may  recur  occasionally  and 
especially  when  certain  foods  are  used;  and  it  is  accompanied  by 
violent  retching  and  strangling,  and  the  substances  rejected  are 
streaked  with  blood.    There  may  be  intervals  when  this  tendency 


964  GESOPHAGUS. 

to  vomiting  quite  vanislies,  and  hence  such  symptoms  arc  easily 
confounded  with  gastric  ulcer  or  cancer. 

Steiger  used  for  the  discovery  of  the  site,  or  sites,  and  the 
determination  of  the  size  and  extent  of  the  stricture,  a  sound 
devised  by  Trousseau,  which  consists  of  a  shaft,  on  the  penetrat- 
ing end  of  which  are  olive-shaped  enlargements,  which  increase 
in  size  from  the  lower  end  upwards,  so  that  if  one  enlargement 
passes,  this  or  another  enlargement  may  be  arrested  by  a  stricture 
lower  down;  nnd  thus  the  site  of  stenosisis  is  found  and  its  size 
determined.  lie  finds  that  there  may  be  more  than  one  strictured 
point,  with  an  intermediate  s})ace  of  normal  calibre.  As  a  rule, 
the  stricture  is  only  for  a  short  distance,  yet  it  may  be  a  half 
inch  or  more  in  length.  There  ma}''  be  a  stricture  near  the  stom- 
ach and  one  or  more  higher  up.  The  sound  touching  and  enter- 
ing the  stricture  causes  pain;  and,  in  withdrawing  the  sound, 
particles  of  food,  mucus  and  blood  may  be  drawn  up.  Steiger 
depends  mainly  on  the  sound  as  a  means  of  treatment.  Should 
there  be  ulceration  accompanying  the  stricture,  Iloppe  gave 
muriate  of  ammonia,  one  grain  daily,  mixed  with  sugar;  he 
claimed  thus  to  have  cured  oesophageal  stricture. 

Boiling  water,  steam,  and  heated  fluid,  as  tea  or  coffee,  from 
accident  or  inadvertent  ingestion,  have  burned  the  inside  of  the 
upper  part  of  the  alimentary  canal.  Except  in  cases  of  explo- 
sion of  steam  boilers,  such  accidents  usually  are  seen  in  the 
child,  whose  tender  years  and  limited  experience  have  not  taught 
it  to  dread  fire.  Within  the  writer's  observation  the  spout  of 
the  heated  tea  or  coffee-pot  has  tempted  the  young  mouth  to  filch 
a  draught  of  the  scalding  fluid.  Such  heated  fluid  seldom  reaches 
far  into  the  oesophagus,  but  does  its  work  chiefly  w^ithin  the 
mouth  and  the  pharynx,  since  the  violently  irritated  muscles  at 
once  contract,  and  thus  naturally  resist  the  further  ingress  of  the 
fluid,  and  they  expel  it.  The  burning  action  rarely  reaches 
beyond  the  upper  part  of  the  oesophagus. 

The  steam  from  highly  heated  water,  as  from  a  boiler  which 
explodes,  may  enter  the  mouth  and  pass  thence  downwards;  and 
as  it  does  so  it  penetrates  towards  the  lungs  rather  than  towards 
the  stomach,  so  that  the  lesion  is  chiefly  in  the  air-passages. 
Whether  from  steam  or  water  which  has  been  heated  to  over  one 
hundred  and  sixty  degrees  Fahr.,  the  effect  of  the  heat  is  to 
coagulate  the  albuminoid  element  of  the  mucous  membrane,  and 
destroy  the  vitality  of  the  latter;  and  such  coagulation  may  reach 
into  the   submucous   structures,  provided   the   heat  be   intense 


STRICTURE    OF    THE    ESOPHAGUS.  965 

enough.  The  structures  so  burned  soon  slough  from  the  unburned 
tissues,  and  thus  a  raw  surface  remains,  which,  in  healing,  con- 
tracts and  lessens  the  calibre  of  the  pharynx  and  the  upper  portion 
of  the  oesophagus.  And  this  contractile  process,  which  is  com- 
mon to  all  parts  of  the  buccal  and  pharyngeal  cavities,  and 
especially  so  in  the  lower  part  of  the  pharynx,  continues  in 
action  long  after  the  surface  has  healed,  and  may  proceed  to  such 
an  extent  that  the  canal  is  reduced  to  a  narrow  fistula. 

The  treatment  of  such  a  burn  should  have  two  aims:  one 
immediate,  to  counteract  the  early  detachment  of  the  -burnt  sur- 
face; and  one  later,  to  oppose  the  cicatricial  narrowing  of  the 
canal.  For  the  first  purpose  cold  should  be  used  in  the  form  of 
ice  water;  and,  to  get  the  best  effect  of  this,  let  fragments  of  ice 
be  taken  in  the  mouth  and  allowed  to  dissolve,  and  the  water  to 
be  swallowed.  To  retard  the  detachment  of  the  burnt  mucous 
tissue,  an  astringent  should  be  used ;  and  for  this  the  decoction 
of  oak  bark,  or  of  Peruvian  bark,  may  be  locally  applied,  or 
tannin  in  iced  water  may  be  used. 

As  soon  as  the  dead  surface  has  detached  itself,  and  the  new- 
formed  separative  tissue  commences  to  undergo  the  regressive 
action  of  the  final  stage  of  cicatrization,  in  which  the  canal  will 
be  narrowed,  this  must  be  counteracted  by  the  introduction  of 
a  round  sound,  which  may  be  solid  or  hollow.  If  a  solid  one  be 
used,  it  should  be  passed  several  times  daily;  not  less  than  once 
in  every  six  hours ;  and  should  this  not  arrest  the  tendency  to 
narrowing,  then  the  sound  should  be  used  every  three  or  four 
hours.  For  this  work,  a  black  rubber  instrument,  similar  to 
the  urethral  sound,  is  the  best.  To  introduce  this,  the  head 
must  be  turned  well  backwards,  the  mouth  well  opened,  when,  the 
distal  end  of  the  sound  being  curved  to  correspond  to  the  axis  of 
the  pharynx,  it  is  passed  into  the  oesophagus.  Should  the 
instrument  catch  on  the  posterior  wall,  it  must  be  retracted  and 
then  the  point  being  turned  in  another  direction,  the  attempt  to 
carry  it  down  is  repeated;  and  such  manipulation,  if  not  done 
with  too  much  effort,  will  always  succeed  in  carrying  the  instru- 
ment into  the  oesophagus.  The  patient,  if  an  adult,  can  soon 
learn  to  do  this  himself 

These  repeated  introductions,  however,  of  the  sound  are 
objectionable,  since  one  may  thus  irritate  the  wounded  surface, 
and  cause  it  to  bleed;  to  avoid  such  irritation,  a  permanently 
lying  sound  may  be  placed  in  the  oesophagus;  and  this  should 
be  hollow,  so  that  nutrient  material  may  be  passed  through  it 


966  CESOPHAGUS. 

into  the  stomach.  Such  a  tube  should  pass  through  the  lower 
meatus  of  one  nostril,  and  be  fastened  at  the  nostril,  so  that  it 
cannot  escape  downwards.  This  tube  must  be  of  llexible  rubber, 
and  the  j)ortion  which  lies  in  the  nose  must  be  smaller  than  that 
which  lies  beyond;  especially  in  the  adult;  but  in  the  child,  the 
tube  may  be  of  uniform  calibre.  That  used  in  the  adult  of 
unequal  calibre  should  have  the  large  portion  introduced  first 
towards  the  stomach ;  then  having  passed  a  thread  through  the 
nostril  by  means  of  a  looped  wire,  the  end  of  the  tube  having 
been  attached  to  the  thread,  it  is  drawn  through  the  nostril  from 
behind  forwards,  and  secured  in  position  by  ligature  and  plaster. 
Through  such  a  tube,  nutrition  can  easily  be  maintained;  and 
to  successfully  resist  cicatricial  contraction,  the  tube  must  be 
used  for  man}'-  M'ceks.  It  should  be  removed,  cleansed,  and 
reintroduced  every  week. 

The  swallowing  of  an  escharotic  liquid,  for  example,  of  a 
concentrated  alkaline  or  acid  solution,  destroys  the  surface  of  the 
pharynx  and  oesophagus  as  quickly  and  extensively  as  does 
boiling  water.  In  such  a  case  the  medical  attendant  should 
make  speed  to  administer  a  neutralizing  agent,  viz.,  dilute  acetic 
acid,  in  case  caustic  potash,  soda  or  lime  have  been  swallowed. 
Instead  of  an  acid,  one  may  use  olive  oil  or  any  other  oil  which 
miglit  be  at  hand.  But  in  case  an  acid  has  been  swallowed,  then 
an  alkaline  basic  agent  should  be  used:  for  exam})le,  a  solution 
of  soda  or  potassa.  By  thus  proceeding,  the  destructive  action 
of  the  escharotic  can  be  lessened;  and  proba])ly,  the  exfoliation 
of  the  mucous  membrane  reduced  to  a  thin  stratum  of  structure. 
And,  afterwards,  the  oesophageal  tube  above  mentioned  should 
be  introduced,  and  the  treatment  pursued  as  described  in  case  of 
burning  by  steam  or  hot  water. 

After  the  inner  surface  of  the  oesophagus  has  been  healed,  the 
process  of  contraction  continues  for  a  long  period;  so  that  the 
calibre  of  the  tube  gradually  diminishes,  and  sometimes  it  is 
almost  reduced  to  an  impermeable  condition;  and  not  infre- 
quently the  patient  only  reaches  the  surgeon  when  this  imper- 
meable condition  has  arisen.  Two  such  patients  have  been  seen 
by  the  author;  in  one  the  contraction  had  arisen  from  the  child 
attempting  to  swallow  sulphuric  acid;  in  the  other  case,  the 
cauterizing  agent  was  a  solution  of  caustic  potash;  and  the  latter 
child  did  not  remain  under  observation  until  the  completion  of 
the  case.  In  the  child  whose  mouth  and  j)harynx  had  been 
severely  burned  by  sulphuric  acid,  healing  had  occurred,  and 


STRICTURE    OF    THE    ESOPHAGUS.  967 

the  lower  part  of  the  pharynx  was  narrowed  to  a  fissure  so  small, 
that  only  liquid  material  could  pass  slowly  through  it.  The 
most  narrow  portion  was  where  the  pharynx  merged  into  the 
oesophagus.  The  treatment  consisted  in  the  use  of  long-bladed 
forceps  and  assorted  India  rubber  sounds.  The  forceps  had 
long  blades,  which  were  of  the  same  curve  as  the  pharynx,  and 
the  blades  could  be  separated  beyond  the  normal  diameter 
of  the  canal.  When  this  instrument  was  introduced  into  the 
stenosed  part,  the  handles  were  opened  and  retained  so  by  a 
cork,  which  was  placed  between  them;  and  thus  the  blades  were 
separated  and  caused  to  press  on  the  sides  of  .the  passage.  After 
this  had  been  continued  for  five  or  ten  minutes,  the  instrument 
was  removed  and  the  round  sound  introduced.  By  this  treat- 
ment continued  for  three  months,  a  stricture  tliat  was  nearly  im- 
permeable was  overcome,  and  the  child's  throat  restored  to 
nearly  normal  condition. 

Certain  morbid  agencies  acting  on  the  pharyngeal  and  oesoph- 
ageal wall  finally  cause  stricture;  examples  of  such  disease  are 
syphilis  and  tubercular  disease.  Each  of  these  may  encroach  on 
the  canal  through  neoplastic  development  and  lessen  its  calibre; 
thus  the  gummatous  syphiloma  and  the  tubercular  growth  may 
develop  in  the  wall,  and  growing  inwards,  lessen  the  canal. 
After  such  encroaching  neoplasm  has  existed  for  a  time,  it  may 
ulcerate  and  the  canal  temporarily  be  restored  to  normal  calibre; 
and  later  through  cicatrization,  strictural  deformity  may  arise. 

Cognate  to  the  causal  agency  just  described  is  that  of  epithe- 
lioma or  sarcoma  originating  in  the  pharyngo-oesophageal  wall ; 
the  former  occurring  much  oftener  than  the  latter.  In  the  aged 
subject  and  where  difficulty  of  swallowing  has  appeared,  and  is 
•gradually  increasing,  malignant  disease  may  rationally  be  sus- 
pected. As  the  disease  proceeds,  the  patient  will  emaciate 
through  insufficient  nutrition,  and  finally  present  the  character- 
istic countenance  of  malignant  disease.  The  sound  will  be 
interrupted  by  a  well-defined,  resistant  and  unyielding  indura- 
tion. The  swarthy  or  irregularly  pigmented  skin  of  the  patient, 
his  emaciation  and  general  .  vital  depression,  the  constantly 
increasing  dysphagia  and  stenosis  detected  by  the  sound,  are 
symptoms  clearly  indicating  the  existence  of  malignant  disease 
in  the  oesophagus. 

An  occasional  causal  agency  of  stricture  here  is  the  polypoid 
neoplasm,  which  may  develop  from  the  inner  wall  of  the  pharynx 
or  oesophagus.     Such  a  neoplasm  may  be  sessile  or  pedunculated 


968  CESOPHAGUtf. 

ill  its  mode  of  origin,  and  may  vary  in  volume  from  that  of  a  pea 
to  much  larger  dimensions.  In  a  case  of  tiiis  kind  reported  to 
the  writer,  the  growth  obtained  such  dimensions  that  it  wholly 
filled  the  oesophagus,  and  caused  the  death  of  the  patient  through 
starvation.  It  was  discovered  at  the  necropsy  that  the  tumor  was 
situated  so  near  the  })harynx  that  its  removal  could  easily  have 
been  effected. 

In  the  case  of  such  polypoid  growth,  an  ai^propriate  treat- 
ment would  be  to  remove  it  by  means  of  forceps  through  the 
pharynx;  and  should  this  not  be  practicable,  then  an  opening 
should  be  made  through  the  neck  by  oesoi'.hagotomy,  and  the 
tumor  reached  and  removed.  Such  operation  would  be  a  safer 
method  than  prolonged  groping  to  seize  an  unseen  object;  and 
when  seized  the  work  of  removal  would  probably  be  imperfectly 
done. 

While  these  pages  have  been  passing  through  the  press,  the 
Avriter  has  removed  a  growth,  of  suspected  sarcomatous  nature, 
from  the  lower  part  of  the  right  lateral  wall  of  the  pharynx. 
This  tumor  had  close  connection  with  the  anterior  (upper)  face 
of  the  epiglottis.  It  was  an  inch  in  its  long  diameter.  The 
operation  consisted  in  first  performing  tracheotomy,  and  the 
insertion  of  a  tracheal  canula;  next  the  external  carotid  artery 
was  tied,  and  then  just  behind  the  angle  of  the  jaw  an  opening 
was  made  into  the  pharynx;  and  then  the  lower  jaw  was 
depressed,  and  retained  so  by  an  interdental  gag,  permitting  one 
hand  to  enter  the  mouth  and  force  the  growth  into  the  wound, 
so  that  it  could  be  dissected  out,  and  its  removal  safely  effected. 
The  case  proceeded  well  until  ^the  fourteenth  day,  when  bleeding- 
occurred  from  the  site  of  the  ligated  artery;  and  to  control  this 
htemorrhage,  the  common  carotid  artery  was  tied.  Ten  days 
aiterwards,  there  was  severe  bleeding  again  from  the  floor  of  the 
sloughing  wound  which  penetrated  into  the  pharynx;  and  this 
blood  appeared  to  come  from  the  internal  jugular  vein  near  its 
origin  at  the  base  of  the  skull.  To  arrest  this,  a  piece  of  sponge 
was  crowded  into  the  bleeding  cavity,  and  held  there  by  digital 
pressure.  After  three  days,  the  tamponing  sponge  was  carefully 
removed  and  replaced  by  another.  By  a  continuance  of  this 
course  for  three  weeks,  during  which  faithful  fingers  and  a 
tractable  patient  mutually  aided  each  other,  the  bleeding  was 
controlled,  the  wound  healed,  and  the  life  of  the  patient  saved. 
The  results  obtained  in  this  case  renew  the  writer's  grateful  obli- 
gations to  Otto  Weber  for  the  knowledge  derived  from  him  of  the 
valuable  properties  of  sponge  as  a  mechanical  h?emostatic. 


STRICTURE    OF    THE    -ESOPHAGUS.  069 

The  pharyngo-oesophageal  tube  may  be  partly  or  entirely 
occluded  by  the  lodgment  of  a  foreign  body  in  it.  The  history 
of  the  case  would  indicate  the  nature  of  the  causal  agency  and 
throw  light  on  its  nature;  and  verification  of  the  same  may  be 
made  with  the  sound.  And  to  relieve  the  patient,  an  attem23t 
must  be  made  to  remove  the  obstructing  agent  with  properly- 
devised  forceps,  as  will  be  more  fully  described  hereafter. 

Obstruction  may  arise  from  some  growth  encroaching  on  the 
wall  of  the  canal;  and  the  invading  agent  may  be  a  solid 
neoplasm ;  or  it  may  be  an  aneurismal  or  a  cystoid  tumor.  A 
solid  tumor  may  be  of  adenoid  or  goitrous  character;  also  a 
carcinomatous  or  sarcomatous  growth  contiguous  to  the  canal 
may  so  press  on  the  latter  as  to  interrupt  its  continuity.  In  the 
event  of  such  tumor  not  contracting  adhesion  with  the  pharynx 
or  oesophagus,  the  latter  will  recede  before  the  pressing  agent,  and 
continuity  remain,  despite  the  encroachment  on  the  canal;  the 
involvement,  however,  of  the  wall  in  a  malignant  neoplasm 
inevitably  leads  to  partial  or  complete  occlusion  of  the  canal. 

One  of  the  most  dangerous  of  occlusive  agencies  acting  parie- 
tally,  is  the  aneurismal  tumor,  which  may  arise  from  the  con- 
tiguous aorta  in  the  thorax,  or  from  the  primitive  carotid  in  the 
neck;  the  aortic  aneurismal  tumor  being  the  more  perilous  on 
account  of  the  magnitude  and  the  inaccessibility  of  the  vessel. 
The  occlusion  of  the  oesophagus  by  the  aortic  aneurism  is  less 
frequent  than  one  might  apprehend  from  the  closeness  of  the 
vessel  to  the  oesophagus.  A  number  of  cases  have  been  recorded 
in  which  the  aortic  tumor  burst  into  the  oesophagus,  causing 
speedy  death.  The  case  of  the  surgeon  Liston  is  famous,  in  whom 
a  thoracic  aortic  aneurism  burst  into  the  oesophagus,  and  after 
the  loss  of  an  enormous  quantity  of  blood  by  vomiting,  the 
patient  had  a  respite  for  several  months,  when  the  tumor  reopened 
and  death  soon  occurred  from  hsemorrhage. 

Narrowing  of  the  pharyngeal  or  oesophageal  canal  may  be 
caused  by  an  abscess  or  collection  of  pus  outside  of  the  passage, 
which  attains  such  a  volume  that  it  forces  the  wall  adjacent  to  it 
against  the  opposite  side.  Such  pus  may  have  a  prsevertebral 
site;  or  it  maybe  situated  in  the  mediastinum,  arising  in  the 
latter  case  from  the  suppuration  of  the  mediastinal  glands. 
Immediate  relief  may  come  in  such  cases  from  the  abscess  burst- 
ing into  the  canal  and  the  pus  thus  escaping.  The  rupture  of 
such  abscess  may  be  caused  by  the  pressure  of  the  dilating 
sound,  or  swallowed  food;  similarly  to  what  occurs  in  peri- 
urethral abscess  from  the  passage  of  the  catheter  or  sound. 
62 


970  OESOPHAGUS. 

In  the  after  treatment  of  cases  of  the  kind  mentioned,  caution 
must  be  exercised  in  the  ingestion  of  nutrient  material,  that  tlie 
latter  does  not  penetrate  the  cavity  of  the  abscess,  and  lodging 
there,  maintain  the  suppuration.  To  avoid  this,  the  materials  of 
food  should  be  passed  to  the  stomach  through  a  tube. 

A  long-continued  irritation  of  the  oesophageal  walls  may  end 
ill  their  hypertrophy,  which  has  been  seen,  in  a  case  reported  by 
Fontan,  to  proceed  to  such  an  extent,  as  to  occlude  the  canal  and 
destroy  life  by  inanition. 

Unexpected  relief  has  sometimes  come  to  the  patient  of 
pharyngeal  or  oesophageal  stenosis  througli  gangrene  or  slougi)- 
ing  of  tlie  narrowed  part;  such  may  occur  in  malignant  disease, 
for  example,  epithelioma.  Though  relief  occur  in  this  way  it 
can  be  but  transient,  since  the  advancing  disease  would  probabh^ 
soon  appear  in  the  adjacent  structures,  and  thus  induce  narrow- 
ing above  and  below  the  ulcerated  breach.  Such  cases  would  be 
but  slightly  amenable  to  treatment;  the  dilating  sound  could 
give  only  temporary  aid,  and  its  use  must  soon  stimulate,  rather 
than  lessen  the  growth  of  the  neoplasm. 

As  shown,  stricture  of  the  pharyngo-oesophageal  canal  may 
arise  from  a  number  of  agencies,  which,  when  studied  as  to  site, 
mav  be  grouped  in  three  classes :  one  situated  adjacent  to  but 
quite  outside  of  the  canal;  a  second  class  seated  in  the  wall 
itself;  and  a  third  one.  in  which  the  causal  agent  arises  from  the 
inner  wall ;  and  a  fourth  class  might  be  added,  in  which  the 
occlusion  is  from  a  foreign  body,  lodged  in  the  passage. 

Certain  general  symptoms  are  common  to  stenosis  arising 
from  any  of  the  causes  comprised  in  these  classes.  These  symp- 
toms are  greater  or  less  difficulty  of  swallowing,  pain  or  uneasi- 
ness in  this  act,  emaciation  from  defective  nutrition,  and  other 
conditions  determined  by,  and  dependent  on,  the  nature  of  the 
cause. 

The  act  of  swallowing  will  be  imperfect  or  embarrassed, 
according  to  the  site  of  the  stricture :  for  example,  should  this  be 
high  in  the  canal,  the  ingesta  will  scarcely  enter  the  ])assage;  but 
if  the  obstruction  be  low  down,  then  the  material  will  have 
normal  passage  through  the  pharynx,  and  suffer  detention  below. 
In  the  commencement  of  the  trouble,  there  is  merely  a  hesitation 
in  swallowing,  the  act  is  prolonged.  Presently,  the  patient  is 
compelled  to  select  his  food;  he  eschews  the  solid  and  uses  that 
which  is  liquid  or  semi-fluid  ;  he  is  much  more  careful  than 
formerly  to  masticate  his  food  thoroughly.     And  if  the  narrowed 


SPASM.  971 

portion  be  low  down,  the  ingested  material  may  collect  there  in 
considerable  quantity,  and  finally  be  regurgitated ;  and  perhaps,, 
as  done  by  the  ruminant,  it  is  rechewed  and  reswallowed;  or  lying 
a  long  time  in  the  canal,  it  undergoes  a  change,  sometimes 
named  oesophageal  digestion. 

The  accumulation  of  the  food  in  the  oesophagus  finally  causes' 
a  dilatation  above  the  stenosed  portion,  and,  as  a  result  of  this,  the 
muscular  wall  will  become  attenuated  and  less  able  to  act  on  the 
contained  matter.  Should  the  lodgment  be  in  the  cervical  por- 
tion of  the  oesophagus,  the  patient  learns  to  aid  the  latter  in  its 
propulsive  work  by  pressing  the  arrested  mass  downwards. 

The  increased  work  of  the  oesophagus  induces  uneasiness,, 
fatigue,  and,  finally,  pain.  The  eff'ort  to  swallow  may  tear  the 
.wall,  and  thus  lead  to  an  ulcerative  breach,  which  is  painfully 
irritated  by  the  contact  and  pressure  of  the  pressing  material. 

And,  besides  the  pain  thus  awakened  in  the  oesophageal  wall, 
the  accumulated  material  pressing  against  the  trachea  can  induce 
a  sense  of  suffocation.  Also,  respiratory  disturbance  might  arise 
from  pressure  on  the  vagi,  of  which  the  left  rests  on  the  front 
wall,  and  the  right  one  on  the  posterior  wall  of  the  affected 
canal.  And  the  proximity  of  the  aorta  in  the  thorax  is  such 
that  the  descending  bolus  may  protrude  against  the  vessel,  and 
become  a  disturbing  element  in  the  movement  of  the  blood, 
demanding  a  greater  cardiac  effort  to  overcome  and  pass  the 
obstructing  agency;  and  though  this  be  slight,  yet  it  must  be 
mentioned  in  an  enumeration  of  causes  which  trammel  the  free 
movement  of  the  blood. 

Spasm. — In  1870  Hamburger  wrote  extensively  on  spasm  of 
the  oesophagus,  of  which  he  makes  a  migrating  or  movable  form 
and  a  fixed  form. 

Migrating  spasmodic  stenosis  is  the  usual  one;  in  this  the 
spasm  commences  at  some  inferior  point,  and  thence  travels 
upwards,  and  seats  itself  in  some  special  point.  A  mild  form  of 
this  is  globus  hystericus,  in  which  the  spasm  travels  upwards,, 
and  is  so  mild  in  its  character  that  it  is  painless  and  does  not 
hinder  swallowing.  But  in  a  more  active  form  the  spasm  may 
continue  for  hours,  and  the  effort  to  swallow  is  painful;  and  in 
such  a  case  one  may  suspect  organic  trouble.  In  a  third  degree, 
the  spasm  is  still  more  severe,  and  is  attended  by  reflex  disturb- 
ance, in  which  breathing  is  disturbed.  In  those  cases,  swallow- 
ing is  quite  impossible,  and  even  the  sight  of  food  excites 
strangling  movements. 


972  CESOPHAGUS. 

(Esopliageul  spasm  may  be  caused  by  erosion,  catarrh,  or 
worms;  yet  tlie  cause  may  be  quite  outside  of  the  oesophagus. 
It  occasionally  occurs  in  the  nervous,  antemic,  depressed,  and 
chlorotic  subject.  As  remote  agencies  are  leucorrhea,  ulceration 
of  the  cervix  uteri,  uterine  fibroma,  or  some  abnormal  position 
of  the  fo-tus  in  the  uterus. 

The  migrating  spasm  is  to  be  treated  by  baths,  arsenic, 
quinine,  atr(>})ine,  opium  and  its  derivatives. 

Spasmodic  stricture,  \vl)ich  is  localized,  is  much  rarer  than 
the  movable  form.  The  sound  here  finds  an  obstruction,  which, 
under  some  pressure,  gives  way.  From  a  small  number  of  obser- 
vations of  Hamburger,  he  concludes  that  this  localized  form  of 
stricture  is  the  premonitory  symptom  of  approaching  cancer  of 
the  stomach;  in  a  few  cases  of  the  kind  necropsy  discovered 
cancer  in  the  stomach,  though  the  oe.sophagus  was  found  in 
sound  condition. 

There  are  phenomena  present  in  the  act  of  deglutition  which 
are  not  alone  perceptible  to  the  patient,  but  it  is  claimed  that 
tliey  can  be  discovered  by  auscultation.  The  subject  of  stenosis 
feels  that  the  material  ingested  successively  halts  and  advances 
until  it  traverses  the  narrowed  part  of  the  canal.  Hamburger 
has  made  a  study  of  the  sounds  which  are  heard  as  material 
traverses  the  narrowed  canal.  He  makes  three  stages  or  degrees 
of  the  stenosis.  In  the  first  degree,  in  the  passage  downward  of 
fluids,  there  may  be  heard  bubbles,  which  pass  from  below 
upwards  through  the  descending  fluids.  In  a  greater  degree  of 
narrowness,  there  is  heard  a  trickling  or  gurgling  sound;  and  in 
the  third  stage,  which  approaches  impermeability,  there  is 
detected  the  sound  of  materials  ascending  in  the  act  of  regurgi- 
tation. Hamburger  claims  that  a  study  of  these  sounds  will 
give  more  accurate  information  concerning  the  degree  of  narrow- 
ness than  can  be  learned  through  using  the  sound;  also  that  the 
site  of  the  stricture  can  thus  be  located,  and,  further,  that  auscul- 
tation can  be  utilized  to  determine  the  progress  that  is  being- 
made  in  treatment.  The  writer  will  admit  that  long  training  of 
the  ear  might  enable  the  auscultator  to  attain  such  power  in  dis- 
crimination; but  if  he  persevere  in  the  use  of  the  sound,  he  will 
attain  great  diagnostic  accuracy  with  far  less  labor,  and,  in  fact, 
learn  thus  to  discover,  with  approximate  certainty,  the  character, 
nature,  and  extent  of  the  stricture.  And  this  leads  to  a  consid- 
eration of  this  method  of  exploration. 

The  oesophageal  sound  should  measure  in  its  entire  length 


SPASM.  973 

twenty-four  inches,  of  which  five  inclies  will  serve  for  tlie  handle. 
Inventive  genius  has  produced  sounds  of  various  forms  and  of 
diverse  materials.  A  not  infrequent  one  is  that  constructed  of 
soft  flexible  rubber,  similar  to  that  of  the  urethral  sound.  That 
of  black  rubber  is  preferable,  since  the  vulcanized  rubber  finally 
hardens  and  is  liable  to  break,  while  the  former  is  more  perma- 
nent in  its  structure  and  elasticity.  A  good  instrument  is  a 
sound  with  a  waxed  end,  which  will  receive  and  retain  an 
impression  of  the  narrowed  part.  One  of  the  most  convenient 
sounds  is  that  of  which  the  shaft  is  whalebone,  and  the  exploring 
end  is  armed  with  an  olive-shaped  body,  in  which  the  shaft 
is  fastened.  There  is  a  screw-like  thread  on  the  end  of  the 
shaft,  which  is  received  in  a  spirally  grooved  hollow  in  the 
olive-shaped  body;  that  is,  the  staff  ends  in  a  screw  which  is 
received  in  a  nut  formed  by  the  olivary  body.  The  staff  is  of 
whalebone,  and  thin  enough  to  be  somewhat  flexible.  There 
should  be  an  assortment  of  the  olive-shaped  bodies,  varying  from 
a  small  size  to  that  approaching  the  normal  thickness  of  the 
oesophagus. 

Instead  of  a  whalebone  staff,  the  latter  may  be  of  silver, 
which  is  flexible  enough  to  adapt  itself  to  the  pharyngo- 
oesophageal  canal.  The  writer  prefers  the  elastic  staff  of  whale- 
bone, since,  when  this  has  been  bent  so  as  to  pass  through  the 
curved  part  of  the  pharynx,  it  becomes  straight  again,  while  a 
staff  of  silver  or  copper  being  curved  remains  so,  and  the  end 
thus  bent  must  press  on  one  side  of  the  canal  as  it  descends. 

To  introduce  the  sound,  let  the  patient  sit  in  a  strong,  low- 
backed  chair,  and  recline  his  head  backwards  as  far  as  he  can, 
with  chin  uplifted  and  mouth  well  open.  The  right-handed 
surgeon  stands  at  the  patient's  left  side,  and  then,  slightly  bend- 
ing the  lower  end  of  the  whalebone  shaft,  he  inserts  this  into 
the  pharynx;  and  as  this  is  done,  the  patient  should  be  directed 
to  swallow  the  terminal  olivary  bulb.  The  bulb  is  often  caught 
in  the  wall  of  the  pharynx  or  larynx,  and,  when  this  occurs,  the 
instrument  must  be  withdrawn  and  inserted  again.  The  car- 
dinal rule  is  that  the  sound  must  be  passed  without  being  forced. 
The  first  few  times  that  the  instrument  is  used  the  canal  resists 
and  prevents  the  onward  movement;  but  with  patient  persever- 
ance and  some  address,  the  instrument  can  be  moved  down- 
wards, provided  the  bulb  is  not  thicker  than  the  canal  to  be 
traversed.  A  spasmodic  action  of  the  muscular. wall  may  catch 
and  hold  the  instrument  temporarily,  and  then  the  wall,  relaxing, 


974  CESOPHAtiUS. 

allows  the  sound  to  proceed.  Such  sijasmodic  constriction  resem- 
bles true  stricture,  yet  its  sudden  disappearance  reveals  the 
actual  condition. 

The  sound  should  be  passed  slowly;  thus  going  it  explores 
and  learns  the  nature  of  the  structures  which  it  traverses:  and 
imparts  this  knowledge  to  tlie  guiding  hand.  Thus  an  abrupt 
stenosis  or  a  gradual  one  is  discovered;  also,  the  handle,  deviat- 
ing in  an}^  direction,  denotes  induration  of  the  opposite  side  of 
the  canal. 

Besides  one  constriction,  there  maybe  two  or  more;  and  these 
may  differ  in  length  and  breadth.  To  learn  the  characteristics 
of  multiple  stricture,  bulbs  of  different  sizes  must  be  affixed  to 
the  staff;  and  by  thus  using  assorted  bulbs,  the  size  of  different 
strictured  points  in  the  canal  can  be  determiued. 

Besides  the  determination  of  the  site,  number  and  breadth  of 
the  strictures,  other  knowledge  can  be  obtained  through  the  use 
of  the  sound.  Thus,  the  dense,  unyielding  structure  of  cicatricial 
tissue,  can  be  felt  and  diagnosticated;  or  if  the  structure  be 
inflamed  and  painful,  the  touch  of  the  sound  will  reveal  this; 
and  lastly,  hardness  on  one  side,  while  the  opposite  wall  remains 
unaffected,  can  be  detected  with  the  sound.  And,  in  a  limited 
portion  of  the  neck,  the  palpating  hand  may  follow  the  descend- 
ing bulb,  and  verify  somewhat  the  obstacles  which  the  latter 
encounters. 

Treatment. — The  treatment  of  a  case  of  stricture  at  some  point 
in  the  pharyngo-oesophageal  canal  varies  according  to  its  nature 
or  causal  agency;  and  accordingly,  it  may  be  placed  under  one  of 
the  following  heads:  medical,  dilating,  escharotic  or  operative. 

In  case  of  narrowing  from  syphilis,  in  the  form  of  gumma- 
tous infiltration  of  the  wall,  the  stenosis  may  rapidly  recede 
before  the  administration  of  mercury  and  iodine.  A  case  is 
described  by  Luton,  in  which  there  was  a  stenosis  almost  occlud- 
ing the  oesoi:)hagus,  in  a  man  aged  forty;  the  suspicion  of  specific 
disease  led  to  the  administration  of  fifteen  grains  of  iodide  of 
potassium,  three  times  a  day.  Under  this  treatment,  the  patient 
was  permanently  relieved,  though  dilatation  by  sounds  had  been 
tried.  And  should  the  stricture  depend  on  malignant  disease, 
the  use  of  the  iodide  of  mercury  has  retarded  the  growth ;  and  in 
the  experience  of  the  writer,  the  growth  has  seemed  to  be 
lessened;  and  his  repeated  observation  would  justify  him  in  the 
general  statement  that  neoplastic  development,  irrespective  of 
nature,  is  lessened  by  the  use  of  the  mixture  of  iodine  and 
mercurv. 


SPASM.  975 

The  dilating  method  has  ah-eady  received  sucli  exhaustive 
consideration  that  hut  little  more  remains  to  be  said,  than  to  add, 
that  besides  the  ivory-bulbed  sound  mentioned,  instrumental 
means  akin  to  this  have  been  resorted  to.  Thus  one  surgeon 
dropped  a  leaden  ball  attached  to  a  cord  to  the  narrow  point,  and 
allowed  this  to  lie  there  for  some  time;  one  sees  in  this  the  peril 
of  detachment  of  the  leaden  body;  and  it  is  clear  that  a  substitute 
for  such  compression  might  be  devised  by  affixing  the  leaden 
body  to  the  handle  of  the  sound  which  has  been  introduced  to 
the  stricture. 

In  case  the  stricture  be  yet  permeable,  the  ingenious  device  of 
Baillarger  may  be  used:  this  consists  of  an  elongated  narrow  sac 
that  is  fastened  to  the  end  of  the  sound,  and  passed  beyond  the 
narrowed  part;  this  done,  the  sack  is  inflated  and  the  staff  then 
withdrawn;  by  such  compression  the  narrowed  calibre  maybe 
widened.  This  procedure  is  reported  to  have  cured  a  case. 
These  devices,  intended  to  replace  the  ordinary  sound,  have  not 
been  generally  accepted;  the  simple  sound, as  in  the  treatment  of 
stenosis  elsewhere,  still  holds  its  place  as  one  of  the  most  satis- 
factory means  of  treatment  in  many  cases  of  oesophageal  stricture. 
In  the  use  of  the  sound  gradual  and  progressive  dilatation  should 
be  aimed  at,  rather  than  immediate  widening. 

Potential  cauterization  has  been  done  as  aid  in  oesophageal 
stricture;  and  for  this  purpose  potassa  fusa  has  been  employed. 
This  is  done  by  taking  a  narrow  tube,  open  at  the  lower  end,  and 
when  this  is  passed  to  the  stricture,  a  small  fragment  of  the  fused 
potash,  as  large  as  the  half  of  a  small  pea,  is  dropped  into  the  tube, 
and  forced  by  a  wire  through  the  lower  opening  into  the  nar- 
rowed part,  and  let  dissolve  there,  and  do  its  escharotic  work; 
thus  an  opening  is  made  into  the  cicatricial  structure,  which 
becomes  an  aid  in  the  use  of  progressive  dilatation  with  a  sound. 
A  less  active  agent  is  nitrate  of  silver,  which  has  been  employed 
in  the  same  way. 

Pharyngotomy  and  oesophagotomy  have  been  done,  both  from 
the  inside  and  the  outside.  When  the  narrowing  is  in  the 
pharynx,  incisions  can  be  made  into  the  inner  wall  with  a 
bistoury.  This  work,  as  the  author  has  found,  can  be  done  with 
almost  any  cutting  instrument,  the  finger  serving  as  guide. 
After  such  incision,  dilating  forceps  may  be  introduced,  widened 
and  withdrawn,  and  thus  narrowness  can  be  temporarily  over- 
come.    And  the  work  can  be  continued  with  large  sounds. 

If  the  stenosis  be  lower  down,  then  an  instrument  similar  to 


976  0ESOPiiA(;rfc>. 

that  used  iu  internal  urethrotomy  might  be  employed,  in  fact, 
any  of  the  modern  urethrotomes  might  be  used.  And  similar 
to  urethral  cutting,  the  work  can  be  done  by  cutting  from  above 
downwards;  or  reversely,  the  in.>?trument  liaving  been  carried 
with  its  concealed  blade  through  the  stenosed  j^art,  the  blade  can 
then  be  uplifted  and  made  to  cut,  as  the  shaft  is  withdrawn. 
Such  cutting  is  better  done  laterally,  that  is,  on  the  right  and 
left  sides,  than  on  the  front  and  posterior  walls ;  for  the  close 
proximity  of  the  vagi  to  the  latter  walls  renders  deep  section  of  the 
same  perilous  to  these  nerves.  And  besides  the  pneumogastric 
nerve,  tlie  aorta  is  close  to  the  posterior  wall,  so  that  the  blade  of 
the  cesophagotome  penetrating  deeply  might  open  this  vessel:  a 
wound  that  would  quickly  end  life.  Hence,  the  cutting  should 
be  towards  the  right  or  the  left  side ;  or  if  done  on  the  front  or 
posterior  wall,  it  should  be  merely  superficial. 

To  be  of  advantage,  this  internal  tiesophagotomy  must  be 
accompanied  by  gradual  dilatation  by  means  of  assorted  sounds, 
as  has  been  described. 

Should  the  dilatation  not  be  practicable  b}^  the  methods 
named,  as  ultimate  aid  a  resort  may  be  to  external  oesophagot- 
omy.  Cases  in  which  this  operation  is  indicated  are  patients  in 
whom  the  pharynx  or  oesophagus  is  the  site  of  sarcoma  or  epithe- 
lioma, through  which  occlusion  has  occurred;  or  in  those  cases 
of  cicatricial  stricture  in  which  relief  cannot  be  obtained  by 
internal  incision  and  progressive  dilatation  ;  and  finally,  it  may 
be  done  to  extract  a  foreign  body  lodged  in  the  lower  part  of  the 
pharynx,  or  in  the  oesophagus. 

External  oesophagotomy  was  first  done  by  Goursauld,  in 
1738.  This  operation,  for  a  long  time,  was  only  resorted  to,  to 
form  a  way  by  which  bodies  lodged  in  the  passage  could  be 
extracted ;  and  in  such  cases,  it  was  not  unfrequently  done  many 
weeks  or  months  after  the  occurrence  of  the  accident  which 
demanded  it.  Later  in  the  history  of  cesophagotomy,  the  opera- 
tion was  done  to  give  a  respite  of  life  to  those  in  whom  death 
from  starvation  was  impending:  such  respite  being  gained  through 
the  formation  of  a  way  by  which  food  can  be  introduced;  or, 
perhaps,  through  such  an  opening  the  occluding  obstacle  maybe 
removed. 

To  perform  this  operation,  in  consequence  of  the  deviation 
of  the  oesophagus  towards  the  left,  the  opening  is  made  on  the 
left  side  of  the  trachea.  As  aid  in  the  work,  a  sound  curved  at 
the  lower  end,  should  be  passed  through  the  mouth  down  to  the 


SPASM.  977 

strictured  portion,  and  then  the  bent  part  of  the  sound  must  be 
turned  towards  tlie  left  and  somewhat  forwards.  On  the  struc- 
ture thus  uphfted,  an  incision  is  to  be  made  through  the  skin. 
Such  cut  should  lie  vertical,  close  to  the  trachea,  in  the  space 
bounded  by  the  trachea  and  the  left  steruo-cleido-mastoid.  The 
cut  is  to  be  continued  deeper  until  it  penetrates  the  space  between 
the  trachea  and  the  left  carotid  artery.  To  aid  in  the  work  the 
trachea  and  artery  should  be  separated  by  means  of  retractors. 
In  this  dissection,  the  fascial  sheath  of  the  vessels  and  nerves 
should  be  left  as  nearly  intact  as  possible:  since,  being  opened, 
excreta  from  the  wound  might  enter  and  gravitate.  The  site, 
hue  and  structure  of  the  oasophagus  will  distinguish  it  from  the 
trachea;  and  the  contained  sound  being  moved,  will  aid  as  a 
guide.  The  point  of  a  tenaculum  being  inserted  into  the 
oesophagus,  it  is  thus  uplifted,  or  pulled  laterally,  at  the  will  of 
the  surgeon,  who  then  penetrates  into  the  canal  by  a  short  verti- 
cal cut.  In  incising  to  the  oesophagus,  as  well  as  in  the  work 
of  cutting  into  it,  the  left  recurrent  laryngeal  nerve  must  be 
avoided.  As  soon  as  the  sound  has  been  reached,  a  grooved 
director  should  be  passed  tlirough  the  wound,  and  the  incision 
elongated  to  the  extent  required.  This  method  is  known  as  that 
of  Verduc-Guattani ;  and  the  cut  made  is  from  two  and  a  half 
to  three  inches  long  in  the  skin. 

The  plan  of  Eckholdt  is  to  make  a  cut  somewhat  oblique 
over  the  lower  part  of  the  sterno-cleido-mastoid  mascle,  and  hav- 
ing split  the  muscle  there  enter  the  space  between  the  sternal  and 
clavicular  legs  of  the  muscle;  thus  opening  backwards  and 
towards  the  trachea,  one  reaches  the  oesophagus.  The  author 
admits  that  the  work  might  be  done  in  this  way,  yet  it  would 
not  be  a  very  direct  route  to  the  oesophagus. 

Begin  says  that  the  procedure  of  Verduc-Guattani  is  an 
impracticable  one,  and  he  substitutes  for  it  another,  which  is 
done  as  follows:  the  patient  must  lie  on  a  narrow  bed,  with  the 
head  and  shoulders  slightly  uplifted,  and  the  head  turned  back- 
wards; thus  placed,  the  neck  is  uplifted  and  easily  accessible  to 
the  operator,  who  makes  an  incision  through  the  skin  between 
the  trachea  and  the  sterno-cleido-mastoid  muscle,  extending  from 
the  sterno-clavicular  joint  to  the  thyroid  cartilage.  As  this  inci- 
sion penetrates,  an  aid  with  a  retracting  instrument  pulls  the 
trachea  inwards,  while  the  surgeon  inserts  his  fingers  underneath 
the  margin  of  the  sterno-cleido-mastoid,  and  pulls  it  laterally 
outwards,  and,  in  so  doing,  he  displaces  the  vessels  outwards,  and 


978 


CESOPIIAGUS. 


gives  tlicni  security  from  his  knife.  The  omo-hyoidean  muscle 
will  be  met  iu  the  middle  of  the  incision,  and  must  be  uplifted 
on  a  grooved  director,  and  divided.  The  a3sophagus  will  now 
present  itself;  and  the  furtlier  work  ])roceeds  differently,  accord- 
ing as  the  operation  is  to  relieve  stricture,  or  to  remove  a  foreign 
body,  or  a  growth  in  the  oesophagus. 

The  oesophagus  when  reached  is  recognized  by  its  rounded 
form,  and  especially,  by  the  movements  which  it  makes  when 
the  patient  is  made  to  swallow.  If  the  sound  be  moved  in 
the  passage  this  will  indicate  its  site.  Besides  the  sound  men- 
tioned by  the  writer,  which  can  be  extemporized  from  a  cathe- 
ter, a  urethral  sound  of  any  flexible  metal,  or  a  thick  wire  that 
has  been  so  doubled  as  to  form  a  loop,  a  special  instrument  has 
been  devised  by  Vacca  Berlinghieri.  This  oesophageal  guide, 
shown   in   Figure   90,  is   provided  with  a  spring  that  can   be 


FiGUr.E  99.     Representing  tlie  instrument  invented  by  Vacca  Berlinghiera  as  guide  in  the 
work  of  opening  the  cesophagns.     Tlie  spring  is  shown  uplifted. 

uplifted  so  as  to  render  the  wall  of  the  passage  prominent. 
When  the  instrument  is  })assed  down,  the  side  containing  the 
spring  is  directed  towards  the  incision,  and  then  the  spring  is 
made  jirominent  by  the  aid  of  a  device  at  the  handle.  That  the 
operator  has  opened  the  canal  will  be  shown  by  the  appearance 
of  mucous  material  in  the  wound. 

Tlie  purposes  of  the  operation  here  considered,  are  j^rimarily 
to  open  a  way  by  which  food  can  reach  the  stomach,  and  the 
patient  rescued  from  death  by  starvation ;  and  subsequently,  to 
uslore  the  continuity  of  the  canal,  and  to  attain  these  ends,  the 
course  to  be  pursued  must  varj'  according  to  the  causal  agency, 
v/hich  oljstructs  the  canal. 

If  the  pharynx  or  oesophagus  be  occluded  by  malignant  dis- 
ease which  has  arisen  there  primarily,  or  which  has  appeared 
there  by  propagation,  then  the  aim  will  be  to  add  a  few  months 
to  the  patient's  life  by  an  opening  into  the  alimentary  canal 
bele)W  the  diseased  part.  Should  the  disease  be  high  in  the  pas- 
sage, the  work  is  easily  done;  an  opening  is  made  in  the  sound 
part  below,  and  a  permanently  lying  tube  is  inserted,  and  fixed 


SPASM.  979 

there  by  being  securely  fastened.  Such  a  tube  should  be  of 
flexible  rubber;  and  to  prevent  its  accidental  escape,  the  outer 
end  may  be  transfixed  by  a  thread  which  is  tied  or  fastened  to 
some  outside  object;  or  the  tube  may  be  transfixed  by  a  safety- 
pin.  Such  a  tube  must  remain  in  the  passage  during  the 
remainder  of  the  patient's  life,  if  he  have  inoperable  or  incurable 
disease  of  the  j)art.  In  case  the  stricture  is  dependent  on  con- 
tracted cicatricial  structure,  then  the  insertion  of  the  tube  may  be 
accompanied  by  some  operation  looking  to  restoration  of  the 
canal.  And  such  operation  may  consist,  in  cas3S  of  slight  con- 
striction, of  simple  longitudinal  incisions  on  the  inner  surface; 
and  then  having  effected  some  dilatation  through  the  use  of 
sounds,  let  a  tube  be  introduced  which  will  prevent  recontraction, 
and  also  serve  for  the  passage  of  nutrient  fluids. 

In  such  a  patient  progressive  dilatation  should  be  continued, 
in  which  the  sound  is  passed  down  through  the  mouth.  In  the 
event  that  the  canal  has  been  converted  into  a  hard  fibrous  cord 
of  limited  extent,  then  an  effort  may  be  made  to  restore  continuity 
by  excising  the  affected  part,  and  reuniting  the  ends  by  suture ; 
and  through  this  sutured  part  a  tube  should  be  passed  and  let 
remain  for  some  weeks.  And  from  experience  it  has  been  found 
Letter,  that  this  tube  enter  an  opening  made  in  the  sound  wall 
above  the  narrowed  part;  and  such  opening  may  be  formed  by  a 
continuation  upward  of  the  wound  which  was  made  in  the  work 
of  excision.  After  healing  and  union  of  the  ends,  the  tube  may  be 
removed,  and  the  work  of  maintenance  of  calibre  be  continued 
by  the  use  of  sounds  passed  through  the  mouth. 

There  remain  to  be  considered  certain  cases  of  stricture  which 
do  not  fall  within  any  of  the  classes  which  have  been  described, 
and  imong  those  may  be  mentioned  dysphagia  lusoria,  dyspha- 
gia spasmodica  and  dysphagia  paralytica. 

Dysphagia  lusoria  was  first  described  by  Bay  ford,  and  it  has 
been  observed  by  Richter,  Valentin  and  others.  It  arises  from 
an  arterial  anomaly,  in  which  the  subclavian  artery  passes 
between  the  oesophagus  and  the  spinal  column.  It  appears  at 
the  time  of  puberty,  and  is  manifested  by  cardiac  palpitation, 
a  sense  of  threatening  sufibcation,  and  the  pulse  in  the  right 
hand  is  weak  and  intermittent;  the  right  arm  is  weak  and 
shrunken,  and  there  is  trouble  in  swallowing ;  and  this  may  be 
constant.  The  treatment  as  counseled  by  Autenrieth  consists  in 
the  frequent  introduction  of  the  sound;  and  his  advice  to  divert 
the  blood  from  the  upper  to  the  lower  part  of  the  body  is  a  mat- 
ter easier  in  precept  than  in  practice. 


980  CESOPHAGUS. 

Spasmodic  dysphagia  depends  on  some  perversion  of  the 
innervation  of  the  i)harynx  and  oesophagus.  This  trouble  is 
usually  seated  in  the  lower  portion  of  tlie  oesophagus;  and  it  is 
so  often  associated  "with  impetiginous  cutaneous  disease,  that 
Clielius  designates  it  an  impetiginous  angina.  It  may  appear 
after  some  catarrlial  affection  of  the  throat.  The  writer,  how- 
ever, has  observed  cases  of  spasmodic  stricture,  in  which  there 
was  no  cutaneous  disease.  In  the  patients,  the  most  of  whom 
were  females,  the  pharyngeal  and  oesophageal  muscles  were 
uuduly  sensitive,  and  became  the  site  of  constrictive  action  from 
slight  cause.  The  attempt  to  swallow,  especially  cold  drinks, 
awakened  such  movement.  The  spasmodic  contraction  often 
ends  in  a  regurgitant  movement,  in  which  the  material  ingested 
is  expelled  upwards.  There  is  an  excessive  watery  or  mucous 
secretion  from  the  canal,  which  may  cause  nausea.  This  spas- 
modic stricture  is  to  be  treated  with  the  sound,  and  the  adminis- 
tration of  remedies  of  a  nature  calculated  to  control  the  irregular 
action.  The  chief  curativ^e  means,  however,  is  the  daily  intro- 
duction of  the  sound,  of  which  the  frequent  contact  with  the  wall 
of  the  passage  will  render  it  less  sensitive  and  irritable.  In  this 
work,  sounds  should  be  used  of  gradually  increasing  thickness; 
and  often,  at  one  sitting,  the  surgeon  may  rise  from  one  of  small, 
to  one  of  much  greater  thickness;  and  in  this  mechanical  treat- 
ment, it  is  the  contact  of  the  instrument  rather  than  its  dilating 
action,  which  accomplishes  the  cure. 

Finally,  there  is  a  form  of  paralysis,  or  rather  inertia,  of  the 
pharynx  and  oesophagus  which  simulates  stricture.  This  has 
been  observed  in  the  aged  subject:  also  in  the  apoplectic  patient; 
and  this  condition  is  indicative  of  grave  intra-cranial  disease, 
or  of  affection  of  the  upper  part  of  the  sj^inal  cord.  A  viscid 
mucus  is  often  excreted  from  the  surface,  and  harasses  the  patient 
by  its  presence.  Solid  matters  are  passed  more  readily  than 
fluids.  Such  patient  swallows  more  readily,  when  he  is  erect, 
and  has  the  advantage  of  gravitation;  and  this  condition  is  a 
hint  to  the  diagnostician  to  search  for  the  cause  intra-cranially, 
or  in  the  spinal  canal  where  it  may  arise  from  meningeal  or 
vertebral  disease. 

When  dependent  on  osseous  disease  or  affection  of  the  me- 
ninges, a  rational  medication  would  be  the  use  of  iodine  locally 
and  internally:  also  pungent  gargles;  for  example,  those  pre- 
pared from  capsicum,  zingiber  and  pyrethrum.  The  oesophageal 
sound  should  be  used ;  yet  when  the  causation  is  considered,  it  is 


SPASM.  981 

evident  that  the  recovery  must  be  doubtful;  and  should  no  relief 
follow  the  use  of  the  means  mentioned,  then  the  patient's  nutri- 
tion must  be  maintained  by  the  introduction  of  liquid  food 
through  a  tube,  which,  provided  with  an  infundibuliform  mouth- 
piece, is  passed  to  the  stomach.  In  the  palsied  throat,  care  must 
be  taken  that  the  instrument  does  not,  in  its  introduction,  stray 
into  the  air-passage,  which  mistake  might  lead  to  drowning  the 
patient.  That  the  material  has  reached  the  stomach  will  be 
manifested  by  the  warm  or  cold  sensation  which  it  will  awaken 
there. 


CHAPTER  XXX. 


FOREIGN    BODIES   IN    THE    PHARYNX    AND    (ESOPHAGUS. 


Bodies  of  every  conceivable  variety  may  find  lodgment  in 
the  pharynx  and  oesophagus:  and  these  in  volume  exceed,  as  a 
rule,  the  diameter  of  these  passages;  yet  the  body  may  not  equal 
this  diameter,  and  still  remain  there  through  the  spasmodic  con- 
traction of  the  containing  walls. 

The  symptoms  of  such  lodgment  are  choking,  strangling  and 
involuntary  efforts  to  expel  the  body.  There  is  a  sense  of  sullb- 
cation  due  to  the  contraction  of  the  glottis,  the  actual  closure  of 
the  larynx,  or  to  the  pressure  over  the  trachea  from  the  body  in 
the  contiguous  oesophagus. 

The  foreign  body  may  be  arrested  at  any  point;  j^et  this 
occurs  oftenest  at  the  upper  or  lower  end  of  the  oesophagus,  the 
narrowest  portions  of  the  passage;  so  that  if  it  be  not  found  in 
the  upper  end,  it  may  be  sought  for  at  the  lower  one. 

The  nature  of  the  material  of  which  the  body  consists,  as  well 
as  the  form  of  the  bod\',  have  a  bearing  on  the  trouble  which 
may  thence  arise.  Thus  a  hard  or  insoluble  body  lodged  in  the 
oesophagus,  and  especially  if  its  surface  be  irregular,  causes  much 
more  trouble  than  one  which  is  soft,  or  has  a  smooth  surface;  if 
the  lodgment,  however,  be  at  the  pharyngeal  entrance  of  the 
canal,  these  distinctions  vanish;  since  occlusion  there  from  a  soft 
body  may  imperil,  or  even  destroy  life.  Thus  South  mentions 
a  necropsy  which  he  made  of  a  man  who,  while  at  his  supper, 
rose  quickly  and  ran  out  of  the  room  and  suddenly  died;  the 
examination  revealed  a  lump  of  beef  which  had  completely 
closed  the  pharynx.  Death  at  the  time  was  supposed  to  be  from 
apoplexy.  Another  case  is  reported  by  South,  in  which  suffoca- 
tion from  similar  cause  was  happily  averted  by  the  patient  him- 
self extracting  the  body  that  had  caught  in  his  pharynx.  Such 
soft  body  descending  lower  might  have  harmless  lodgment,  until 
it  was  loosened  spontaneously,  and  escaped  into  the  stomach; 

( 982 ) 


FOREIGN  BODIES  IN  THE  PHARYNX  AND  CESOPHAGUS.  983 

but  one  which  is  insoluble  erodes  the  wall  on  which  it  presses,' 
and  especially  if  the  surface  be  rough. 

Among  the  numerous  objects  which  have  lodged  in  the  phar- 
ynx and  oesophagus,  the  following  have  often  been  seen:  coins, 
fish-bones,  the  crushed  bones  contained  in  meat  of  different  kinds, 
ill-chewed  articles  of  food,  the  mesocarp  of  fruits,  fragments  of 
wood  and  of  metal,  and  needles,  fish-hooks,  knives,  especially 
the  clasp-knife,  and  blades  and  other  objects  with  which  jugglers 
disport  for  the  amusement  of  audiences;  and  to  complete  the 
enumeration,  there  should  be  added  the  toys  of  children,  which 
intentionally  or  accidentally  have  found  a  resting-place  in  the 
pharynx  or  oesophagus;  and,  finally,  no  small  contingent  of 
these  objects  have  been  furnished  by  the  dentist's  hand,  in  the 
different  forms  of  artificial  teeth,  which,  being  detached  from 
their  place  in  the  mouth,  have  passed  downwards. 

The  surgeon  is  sometimes  consulted  in  reference  to  the  removal 
from  this  passage,  of  a  foreign  body  which  he  fails  to  discover; 
in  such  cases,  the  body  has  found  only  temporary  lodgment,  and 
during  its  sojourn,  it  wounded  the  wall;  this  has  been  seen  where 
a  pin  or  fish-bone  has  been  swallowed.  Such  irritation  of  surface 
is  oftenest  observed  in  the  upper  part  of  the  passage,  where  visible 
inspection  can  be  made.  Such  patients  are  hard  to  convince  that 
the  body  is  not  present  of  which  there  is  so  clear  a  sensation. 
And  the  sensation  remaining  after  a  body  has  been  removed 
may  continue  to  annoy  the  patient  for  some  time.  Thus  suppu- 
ration has  arisen  and  stricture  of  the  passage  resulted. 

The  foreign  body  has  caused  death;  Crequy  in  1860,  reported 
eight  cases  of  death  from  this  cause.  Death  was  partly  due  to 
hunger;  in  some  cases  it  was  caused  by  suppuration,  and  in 
others,  by  haemorrhage  through  sloughing  which  opened  vessels. 
Lavacherie  reported  twelve  fatal  cases  from  sloughing  and 
haemorrhage.  Death  occurred  between  the  sixth  and  tenth  day 
To  avert  such  an  ending  Crequy  recommends  that  the  oesophagus 
be  opened  early,  viz.,  on  the  second  or  third  day. 

In  1868,  Adelmann  of  Prague,  and  Martin  of  Paris,  wrote  on 
foreign  bodies  in  the  cesophagus.  The  report  is  given  of  three 
hundred  and  fourteen  cases;  one-third  of  these  were  bones,  and 
the  remainder  were  chiefly  needles  and  coins.  When  the  bodies 
were  classified  in  reference  to  character  of  surface,  the  number  of 
rough  ones  exceeded  that  of  the  smooth  ones.  Recovery  occurred 
in  one  hundred  and  ninety-one  cases.  Spontaneous  recovery 
occurred  in  several  cases  through  vomiting;  and  in  a  few  patients. 


9S4  FOREIGN  BODIES  IX  THE  PHARYNX  AND  lESOPHAGUS. 

expulsion  occurred  through  sneezing  or  laughing.  Death  occurred 
in  twelve  cases  by  the  body  penetrating  to,  and  piercing  the 
aorta.  The  carotid  artery  was  fatally  opened  in  three  cases;  the 
subclavian  in  one,  and  the  pulmonary  artery  in  one  case,  caus- 
ing death  in  each  patient. 

Kreyser,  in  18-17,  reported  a  death  from  a  body  penetrating 
the  aorta.  The  body  "was  a  bone,  an  inch  long,  wliich  lay  across 
the  oesophagus.  The  luemorrhage  from  the  aorta  was  into  the 
left  pleural  cavity. 

Inasmuch  as  spontaneous  recovery  occurred  in  but  a  small 
number  of  juitients,  Adelmann  teaches  that  instrumental  interfer- 
ence should  be  resorted  to  at  an  early  period ;  instruments 
designed  to  catch  the  body,  should  first  be  tried;  and  these  fail- 
ing to  relieve,  oesophagotomy  should  be  done.  Adelmann  finds 
of  sixteen  cesophagotomies,  that  eleven  recovered. 

Before  resorting  to  the  knife  simpler  measures  should  be 
tiled.  Titillation  of  the  fauces  wliich  provokes  emesis  may  dis- 
lodge and  remove  the  body  by  the  mouth ;  thus  a  barbed  vertebra 
of  a  fish  was  removed  by  the  writer.  And  vomiting  caused  by 
the  introduction  of  forceps  to  catch  the  body,  has  evacuated  the 
latter. 

Where  the  body  is  of  a  harmless  character,  and  cannot  be 
removed  upwards,  Brodie  counsels  to  force  it  dov>'nwards  to  the 
stomach  ;  and  if  this  is  found  impracticable,  then  he  allows  it  to 
remain  in  place,  when  the  body  will  often  slowly  pass  downwards. 
Few  patients,  the  writer  suspects,  would  accept  so  conservative  a 
plan;  the  victim  of  a  body  in  the  oesophagus  is  frightened  and 
anxious  for  its  removal;  he  is  in  no  mood  to  brook  delay  in  the 
work;  and  such  advice  would  but  speed  him  to  a  less  conserv- 
ative counselor. 

Any  article  of  food  which  has  lodged,  and  of  which  the  tex- 
ture is  not  hard,  can  be  caused  to  pass  to  the  stomach  by  pressure 
from  above;  and  this  can  be  done  by  means  of  a  piece  of  whale- 
bone to  which  a  portion  of  sponge  has  been  securely  tied.  The 
usual  probang  employed  in  pharyngeal  treatment  may  be  made 
to  do  such  service.  And  sometimes,  the  propelling  sound  can  be 
aided  by  pressure  with  the  hand  on  the  outside,  in  cases  in  which 
the  body  can  be  felt  externally. 

In  case  the  arrested  object  be  a  pin,  needle,  fish-bone,  or  any 
similar  thing,  it  should  be  extracted,  and  not  pushed  downwards; 
and  to  accomplish  this,  various  instrumental  devices  have  been 
invented,   or  extemporized   by   the   ingenuity   of   the   medical 


FOREIGN  BODIES  IN  THE  PHARYNX  AND  OESOPHAGUS.  985 

attendant.  Such  a  device  was  that  of  Mutter,  who  attached  a 
number  of  looped  threads  to  the  end  of  a  probang,  which  being- 
passed  down  and  twirled  around,  caught  the  object  in  its 
meshes.  The  writer  would  suggest  that  a  small  balloon  fastened 
to  a  hollow  tube  could  be  passed  down,  inflated  with  air,  and  then 
being  withdrawn,  the  object  might  be  caught  and  removed.  The 
effort  should  always  be  made  to  remove  such  body  upwards; 
thus  done  the  patient  is  relieved  of  further  anxiety. 

The  pricking  body  extracted,  there  remains  p.ain  in  the 
oesophagus  for  some  hours;  and  if  this  does  not  abate  soon,  it 
indicates  ulcerative  or  suppurative  action';  or  what  has  been  seen 
in  a  few  cases,  there  was  another  body  which,  remaining,  main- 
tained the  irritation,  until  the  object  was  removed. 

Coins  frequently  find  lodgment  in  the  oesophagus:  it  is 
sometimes  seen  in  the  adult,  though  oftener  in  the  child.  Among 
such  cases  recorded,  that  told  by  Habicot  is  remarkable.  A  boy 
swallowed  nine  pieces  of  gold  (pistoles)  wrapped  in  a  piece  of  cloth; 
the  package  lodged  in  the  narrow  part  of  the  pharynx,  and  caused 
suffocation,  so  that  to  save  life,  tracheotomy  was  done;  impend- 
ing death  being  thus  averted,  the  pistoles  were  thrust  down  with 
a  sound,  and  finally  passed  by  the  rectum.  The  epigrammatic 
comment  of  Habicot  was  that  the  boy's  life  was  saved,  and  the 
gold  was  not  lost. 

A  case  was  seen  by  the  writer,  of  an  old  man  who  had  swal- 
lowed a  silver  half  dollar,  which  lodged  in  the  cesophagus.  An 
exploratory  search  with  a  sound  provoked  vomiting,  in  which 
the  coin  was  expelled.  During  its  sojourn  of  thirty  days  the 
silver  had  become  well  blackened.  The  man  suffered  no  subse- 
quent inconvenience. 

To  remove  coins  the  elder  Graefe  invented  an  instrument 
which  consisted  of  a  long  slender  hollow  handle,  to  the  end  of 
which  were  fastened  rings,  one  of  which  could  be  turned  about 
at  right  angles  to  the  other;  and  in  this  form  the  instrument  was 
withdrawn,  and  the  coin  caught  by  it  and  extracted.  It  may  be 
suggested  that  looped  wires  passed  through  a  flexible  catheter 
could  be  made  to  act  in  the  same  manner  as  the  coin-catcher  here 
mentioned.  Such  an  instrument  might  be  employed  to  remove 
other  bodies. 

Long-bladed  forceps  may  be  used  for  the  extraction.  Such 
forceps  shauld  have  a  curve  corresponding  to  the  axis  of  the 
pharynx;  and  the  joint  of  the  blades  should  be  near  the  lower 
end.  With  such  an  instrument,  by  careful  manipulation,  the 
body  may  sometimes  be  found  and  extracted. 
63 


086 


FOItEIGX  BODIES  IN  TPIE  rHAKYXX  AND  (ESOPHAGUS. 


An  ingenious  instrument  has  been  invented  by  Mathieu  of 
Paris,  wiiich  may  be  named  a  many-jointed  forceps,  and  isslio\\[U 
in  Figure  100.     This    handled  forceps   consists  of  a  number  of 


Figure  100.     Exhibiting  Mathieu's  esophageal  forceps. 


articulated  sections,  the  whole  so  disposed  that  when  the  handles, 
are  opened  or  closed  the  grasping  end  will  open  or  close.  The 
jointed  sections  permit  some  flexibility  of  the  shaft  of  the  instru- 
ment. With  this  instrument  one  can  enter  the  stomach,  and 
thence  remove  an  object;  it  was  first  devised  to  remove  a  key 
from  the  stomach  of  an  insane  man,  and  tlie  extraction  of  the 
key  was  thus  successfully  accomplished.  The  writer  removed 
with  it  a  large  forked  fish-bone  that  was  lodged  in  the  lower 
part  of  the  oesophagus;  this  was  done  by  passing  it  down  to  the 
lower  end  of  the  oesophagus,  then  opening  and  withdrawing  it, 
when  the  bone  was  caught  and  drawn  upwards.  With  this 
instrument  almost  any  object  lodged  in  tlie  passage  miglit  be 
cauglit  and  witlidrawn. 

The  fisherman  has  been  so  maladroit  as  to  cast  his  hook  into 
his  own  throat,  and  to  become  the  subject  of  the  surgeon.  In 
such  a  case  -Miitter,  of  Philadelphia,  succeeded  in  detaching  and 
removing  the  hook  Ijy  passing  the  cord  through  a  coi-k  of  suit- 
able size,  and  then  forcing  the  cork  down  with  a  sound  until  it 
reached  tlie  hook,  which  was  thus  unhooked  from  the  wall,  then 
the  cord  being  pulled  on,  the  hook,  cork  and  all  were  drawn  out 
through  the  mouth.  In  a  case  reported  by  South  the  subject  was 
relieved  similarly  of  his  hook  bypassing  a  perforated  bullet  down 
the  cord  until  it  became  engaged  in  the  hook,  when  the  latter 
was  thus  successfully  withdrawn. 

An  object  of  less  gravity  than  the  preceding  is  the  bristle 
from  the  tooth-brush,  which,  passing  into  the  pharynx,  becomes 
fixed  there,  through  one  end  penetrating  the  mucous  membrane. 
A  small  fish-bone  may  act  similarly;  and  the  object  so  lodged, 
though   innocuous,   may  greatly   distress   the   patient,  and    the 


FOREIGX  BODIES  IN  THE  PHAEYXX  AND  OESOPHAGUS.  987 

reflex  movements  which  it  awakens  in  the  throat,  instead  of 
releasing  the  object,  tend  to  fix  it  more  lirmly  in  its  place.  A 
careful  exploration  of  the  pharynx  will  usually  bring  the  object  to 
view;  or,  failing  to  see  it,  the  surgeon  may  find  it  by  a  search 
with  his  finger.  If  visible,  the  object  can  be  seized  with  forceps 
and  extracted.  Should  it  elude  sight  or  touch,  the  object  may 
sometimes  be  caught  and  removed  by  means  of  a  probang,  to 
which  there  is  attached  a  piece  of  sponge;  by  twirling  and  mak- 
ing various  movements  with  this,  the  object  may  sometimes  be 
caught  and  removed. 

Artificial  teeth  have  frequently  escaped  from  their  place-  in 
the  mouth  and  lodged  in  the  pharynx  or  oesophagus.  Among 
the  earliest  cases  of  this  kind  reported  is  one  contained  in.  Fro- 
riep's  jSTotizen,  in  1845;  the  false  teeth  swallowed  remained  in 
the  oesophagus  until  the  containing  wall  was  penetrated,  the 
aorta  opened,  and  fatal  haemorrhage  ensued,  ten  pounds  of  blood 
were  found  in  the  stomach  at  the  necropsy.  In  1856  Cock,  of 
Guy's  Hospital,  reported  a  case  in  which  a  dental  plate  was  swal- 
lowed ;  a  tube  was  introduced  alongside  of  it,  and  the  patient 
then  given  an  emetic;  this,  failing  to  expel  the  plate,  Cock  per- 
formed oesophagotomy  and  removed  the  body:  the  patient  recov- 
ered. In  1858  Buisl  made  a  necropsy  on  a  drunkard  wdio  had 
swallowed  a  dental  plate  with  two  artificial  teeth;  it  was  nearly 
two  inches  long  and  one  ihch  broad.  This  had  lodged  near  the 
cardia,  and  had  penetrated  the  wall  of  the  gullet,  and  made  an 
opening  into  the  pericardial  sack,  which  was  found  distended 
with  ill-smelling  pus  and  gas.  In  1878,  Maclean,  of  New  York, 
reported  two  cases  in  which  artificial  teeth  had  been  swallowed 
and  had  remained  in  the  oesophagus.  In  one  patient  the  plate  was 
swallowed  during  sleep;  a  sound  was  passed  down  and  used  as  a 
guide  in  opening  the  oesophagus;  the  opening  was  made  on  the 
left  side,  and  the  plate  extracted.  In  the  second  case  the  teeth 
remained  lodged  some  months.  CEsophagotomy  was  performed, 
and,  to  shun  the  recurrent  nerve,  the  opening  was  made  more 
posteriorly  than  was  done  in  the  former  case,  in  which  the  nerve 
was  wounded.  In  each  case  the  wound  was  left  open,  yet  food 
only  escaped  through  it  for  a  short  time,  and  the  wound  soon 
closed. 

This  chapter  may  conclude  with  the  advice  that  when  a  for- 
eign body  has  lodged  in  the  pharynx  or  oesophagus,  an  attempt 
should  be  made  to  remove  it  by  some  of  the  non-operative  pro- 
cedures which  have  been  described;  and,  if  these  prove  ineffec- 


988  FOREIGN  BODIES  IX  THE  I'lfATtYXX   AXD  (ESorilAGUS. 

tual,  then  a  resort  sliould  be  luul  to  oesophagotomy;  ami  in  the 
performance  of  tliis  operation  the  writer  desires  to  enforce  the 
fiict  that  anatomical  perils  are  close  to  the  knife  on  every  side ; 
for  the  field  of  work  is  crossed  above  by  the  superior  thyroid 
artery,  and  below  by  the  inferior  thyroid;  the  deep  position  of  the 
latter  especially  endangers  it;  and  on  the  inside  lie  the  trachea 
and  the  inferior  recurrent  nerve,  so  much  concerned  in  phona- 
tion;  and  on  tlie  outer  side,  close  to  the  knife,  lies  the  common 
carotid  artery.  These  imperiled  structures  may  be  avoided  l)y 
the  diligent  use  of  the  blunt  dissector  and  the  blunt  retractor. 

Should  the  body  lie  in  the  lower  end  of  the  (Te.sophagus,  and 
be  so  impacted  or  impaled  in  the  structures  tliat  it  cannot  be 
extracted  by  a  route  above  the  diaphragm,  then  a  resort  must  be 
had  to  gastrotomy,  in  which,  an  opening  being  made  through 
the  stomach,  the  body  is  extracted  and  the  wound  closed,  accord- 
ing to  rules  derived  from  experience  in  the  treatment  of  wounds 
which  open  the  stomach  or  bowel — a  subject  which  cannot  prop- 
erly be  treated  of  here. 


CHAPTER   XXXI. 


PHARYNGEAL    AND    (ESOPHAGEAL    NEOPLASMS. 


Neoplastic  disease  of  the  pharynx  and  oesophagus  may 
appear  in  benign  or  malignant  form. 

Benign  growths  have  frequently  been  seen  seated  in  the  pos- 
terior wall  of  the  pharynx;  and  in  that  case  springing  from  the 
retro-pharyngeal  fascia,  the  anterior  vertebral  ligament,  the 
periosteum  of  the  upper  cervical  vertebnE,  or  from  the  anterior 
face  of  the  vertebra.  Such  benign  growth  is  constituted  of 
fibrous  tissue,  and,  classified  pathologically,  it  is  a  fibroma. 

The  retro-pharyngeal  fibroma,  following  the  usual  course  of 
an  enlarging  tumor,  develops  in  the  direction  in  which  it  finds 
the  le^st  resistance;  and  hence,  should  it  arise  behind  the  easily 
receding  structures  of  the  pharyngeal  w^all,  the  tumor  will  pro- 
trude prominently  into  the  pharynx.  But  if  the  origin  be  behind 
the  anterior  vertebral  ligament,  or  the  periosteum,  then  the  neo- 
plasm will  be  flat  in  its  form,  and  w'ill  develop  less  forwards  than 
in  the  previous  case.  Again,  the  tumor  may  arise  in  contiguous 
structures  and  appear  secondarily  in  the  pharynx.  And  this 
immigrant  may  then  come  from  the  palatal  or  tlie  laryngeal 
region. 

Such  growth  seated  in  the  posterior  pharyngeal  region  may 
displace  the  tonsils,  invade  and,  partly  or  wholly,  occlude  the 
entrance  of  the  Eustachian  tube,  and  cause  deafness;  or  it  may 
enter  the  choanse  and  interfere  with  the  voice  and  nasal  breath- 
ing. A  yet  more  perilous  encroachment  is  that  in  which  the 
fibroma  obstructs  the  opening  of  the  larynx. 

Another  important  functional  disturbance  is  that  of  dys- 
phagia; the  patient  has  trouble  in  swallowing,  greater  or  less 
according  to  the  site  and  volume  of  the  growth.  In  a  case  seen 
by  the  writer  the  canal  of  the  throat  was  so  attenuated  that  the 
patient  swallowed  with  extreme  difficulty,  and,  through  insuffi- 
cient nourishment,  death  by  starvation  was  imminent. 

(989) 


900  I'lIAllYNCK.M,    AND    (KSUl'II  AciKAL    NKoPLASMS. 

The  tumor,  through  lateral  extension,  may  press  on  the 
internal  jugular  vein  and  the  internal  carotid  artery,  and  thus 
disturb  the  intra-cranial  circulation  through  inducing  aniemia 
or  hyperjemia. 

Treatment. — Such  tumor  must  lie  removed;  and  this  may 
usually  be  done  through  the  mouth,  if  the  tumor  be  discovered 
before  it  has  grown  to  large  dimensions,  or  before  it  has  entwined 
its  root-like  processes  about  the  adjacent  vessels.  Through  the 
mouth  the  writer  has  removed  three  retro-pharyngeal  tumors. 
The  three  subjects  were  adult  males.  In  one  the  tumor  had  so 
nearly  tilled  the  pas.sage  of  the  throat,  that  as  an  aid  in  the  work, 
tracheotomy  was  preliminarily  done.  In  a  second,  the  Rose  posi- 
tion, in  which  the  recumbent  head  is  dependent,  was  u.sed;  and 
in  a  third,  the  patient  lay  recumbent,  with  the  head  somewhat 
elevated.  The  experience  had  in  these  cases  induces  the  writer 
to  advise  preliminary  tracheotomy;  thus  fortified,  the  operator 
proceeds  without  apprehension  that  the  patient  will  be  drowned 
by  his  blood  entering  the  air-passages. 

The  mouth  being  well  opened,  and  the  jaws  retained  asunder 
by  an  interdental  wedge,  a  vertical  cut  is  made  through  the 
mucous  covering  of  the  growth,  and  the  latter  then  detached 
with  a  blunt  dissector  from  the  adjacent  structures.  After  the 
removal,  the  wound  should  be  brushed  with  pure  alcohol,  and 
left  unsuturcd.  Nutrition  should  be  maintained  per  rectum,  or 
through  the  stomach  tube;  and  nothing  except  water  be  per- 
mitted to  come  in  contact  with  the  wound. 

In  case  the  growth  is  inaccessible  by  the  oral  and  buccal 
route,  a  more  direct  one  has  been  proposed  by  Malgaigne,  and 
named  by  him  sub-hyoid  laryngotomy;  but  by  Langenbeck  it  is 
called  sub-hyoid  pharyngotomy. 

Sub-hyoid  phar3'iigotomy  has  been  done  for  the  removal  of 
both  vessels  and  pedunculated  growths  in  the  opening  of  the 
larynx,  and  also  in  the  lower  part  of  the  pharynx.  And  in  case 
it  be  done,  tracheotomy  at  some  lower  point  is  sometimes  neces- 
sary to  insure  uninterrupted  respiration  during  the  removal  of  a 
tumor,  and,  also,  to  permit  the  tamponing  of  the  upper  portion  of 
the  trachea,  so  that  blood  cannot  descend  to  the  lungs. 

To  perform  sub-hyoid  pharyngotom}'^,  a  transverse  incision  is 
made,  two  inches  long,  along  the  lower  border  of  the  body  of  the 
hyoid  bone.  After  division  of  the  skin,  platysma  myoid  and 
sterno-hyoid  muscles,  tlie  thyro-hyodean  membrane  is  reached, 
and  to  aid  in  the  incision  through  this  structure,  it  is  seized  with 


GROWTHS    IX    THE    CESOPHAGUS.  991 

a  pair  of  forceps,  uplifted  and  divided.  The  mucous  membrane 
is  next  severed;  and  in  doing  tliis,  caution  is  to  be  used  not  to 
split  or  penetrate  the  epiglottis,  which  is  attached  to  the  body  of 
the  hyoid  bone.  At  the  termination  of  the  cut  on  each  side,  lie 
the  superior  laryngeal  artery,  and  a  branch  of  the  superior  laryn- 
geal nerve;  those  parts,  however,  are  situated  so  far  to  the  side 
that  the  opening  into  the  pharynx  can  easily  be  made  without 
peril  to  them.  When  this  opening  is  made,  the  epiglottis  should 
be  seized  and  drawn  out  through  the  cut.  As  soon  as  the  thyro- 
hyoidean  membrane  has  been  well  severed  by  this  transverse 
incision,  the  larynx  descends  so  as  to  widen  the  cut  to  an  extent 
that  will  allow  of  attacking  the  growth  which  is  sought  to  be 
removed.  After  the  growth  has  been  removed,  the  wound 
should  be  closed  by  sutures,  and  the  head  bent  forwards  and 
retained  so  by  a  proper  bandage. 

Warts,  Cysts  and  Polypoid  Grouihs  ra  the  (Eso'phagv.s. — Besides 
large  neoplasms,  small  growths  of  wart-like  conformation  occur 
here,  gathered  in  groups,  or  isolated  in  situation;  and  these  are 
oftenest  seen  in  the  aged  subject.  In  the  act  of  deglutition,  the 
frequent  passage  of  materials  over  these  prominences  finally 
erodes  them,  and  causes  a  burning  pain  in  the  part. 

A  cyst  may  arise  here  from  the  closure  of  one  or  more  mucous 
follicles,  and  the  accumulation  of  the  retained  fluid. 

The  polypoid  growth  has  frequently  been  observed  in  the 
oesophagus.  Such  neoplasm  appears  oftenest  in  the  lower  part 
of  the  pharynx,  and  in  the  wall  next  to  the  larynx.  The  fre- 
quent action  of  swallowing  tends  to  displace  such  tumor  down- 
wards, and  to  elongate  its  pedicle.  And,  in  time,  it  may  thus 
acquire  considerable  length;  an  instance  was  seen  by  Rokitansky, 
in  which  the  growth  had  attained  the  length  of  seven  inches; 
and  it  was  two  and  a  half  inches  broad.  And  such  tumors  may 
be  multiple;  or  rising  from  a  common  point,  it  may  divide  into 
two  or  more  branches.  Dermoid  cyst  has  been  seen  here;  and 
cases  of  lipoma  have  been  reported  by  Klebs. 

Such  pendent  tumor  becomes  ulcerated  from  repeated  irrita- 
tion; and  it  has  been  known  to  be  detached,  and  the  patient 
thus  freed  from  his  trouble. 

The  subjective  phenomena  of  the  oesophageal  polypoid  tumor 
are  the  sensation  of  a  foreign  body  in  the  passage;  and  the 
patient  makes  repeated  efforts  to  reject  the  same.  In  conse- 
quence of  the  difficulty  of  swallowing,  the  patient  confines  him- 
self to  licjuid  or  semi-liquid  food;  and  this  is  often  swallowed 


992  PHARYNGEAL    AND    CESOPHACiKAL    NEOPLASMS. 

"with  effort,  a  part  of  it  regurgitatiii<;  and  escaping  tliroiigli  tlie 
month  or  nose. 

Respiratory  disturbance  may  be  produced  through  the  tumor 
pressing  against  the  trachea;  such  pressure  attenuating  the 
calibre  of  the  air-canal.  A  more  dangerous  condition  is  present 
when  the  growth,  being  seated  in  the  upper  part  of  the  oesopha- 
gus, is  carried  upwards  and  falls,  like  a  closing  valve,  on  tlie 
opening  of  the  air-passage.  In  such  state,  the  patient  has  speed- 
ily perished  from  strangulation.  Blood-tinged  mucus  is  some- 
times vomited.  When  of  unusual  volume,  the  tumor  may  cause 
a  swelling  which  is  visible  on  the  neck. 

Besides  the  respiratory  trouble  which  such  j)olypoid  growth 
can  cause,  the  partial  closure  of  the  alimentary  tube  interferes 
with  the  digestion  of  the  normal  quantity  of  food,  and,  conse- 
quently, such  patient  is  inadequately  nouiished. 

In  the  diagnosis  of  these  growths,  the  oesophageal  sound  can 
assist;  an  obstruction  may  be  detected  with  it,  and  the  movable 
or  immovable  nature  of  the  tumor  can  thus  be  determined  to 
some  extent. 

The  proper  treatment  of  these  growths  is  extirpation ;  and 
this  should  be  done  radically;  for  if  a  peduncular  fragment  be 
left  behind,  the  growth  will  reappear.  Different  ways  have  been 
proposed  to  do  this  work.  In  the  earliest  es.says  at  removal,  this 
was  done  by  ligating  the  pedicle  and  permitting  the  tumor  to 
slough  off.  A  second  way  was  to  seize  the  growth  with  forceps, 
and  then  twist  it  off,  or  })luck  it  from  its  attachment  to  the  wall. 
The  growth  has  also  been  cut  off,  without  ligature:  a  metliod  not 
to  be  pursued,  since  troublesome  bleeding  may  thus  ensue.  The 
thermal  cautery  has  been  used:  the  loop  of  the  heated  wire  includ- 
ing the  pedicle  and  cutting  it  off.  Or  if  the  removal  is  not 
possible  by  any  of  these  ways,  then  a  direct  route  may  be  cut  to 
the  growth,  either  through  the  interspace  between  the  hyoid 
bone  and  the  larvnx;  or  bv  external  cesophagfitomy. 

Malignant  Growths  in  the  Pharynx  and  Oesophagus. — E[)ithe- 
lioma,  the  form  in  which  cancerous  disease  here  presents  itself, 
has  often  been  observed  in  the  oesophagus;  but  as  to  its  location 
there,  surgical  opinion  varies.  Zenker,  from  a  series  of  cases 
too  limited  for  a  proper  induction,  finds  that  the  di.sease  occurs 
in  the  upper  part  of  the  canal  in  nearly  fifteen  per  cent  of  tlie 
cases;  and  in  the  middle  portion,  in  fifty-one  per  cent  of  the 
cases;  and  in  the  lower  third,  in  sixty-three  per  cent;  thus,  as 
would  appear  from  these  figures,  the  disease  increases  in  frequency 


MALIGNANT  GROWTHS  IN  PHARYNX  AND  (T:S0PHAGUS.  !J93 

as  one  descends.  Mackenzie,  in  a  series  of  one  hundred  cases, 
finds  the  order  of  occurrence  nearly  reversed:  to  wit,  he  finds 
forty-four  per  cent  in  the  upper  third,  twenty-eight  per  cent  in 
the  middle,  and  twenty-two  per  cent  in  the  lower  third,  and  six 
cases  in  the  lower  half  of  the  canal. 

The  most  usual  sites  of  the  disease  are  where  the  canal  passes 
behind  the  bronchus,  and  where  it  traverses  the  diaphragm;  for 
at  these  points,  the  canal,  in  its  functional  action,  is  more  apt  to 
be  irritated;  especially  so,  where  the  oesophagus  passes  through 
the  diaphragm. 

The  disease  occurs  oftenest  in  ring  form,  in  which  a  transverse 
section  of  the  canal  is  involved  ;  and  such  circular  segment  may 
vary  in  height  from  a  half  inch  to  three  inches.  In  some  cases, 
this  ring-like  invasion  does  not  include  the  whole  circumference; 
a  small  segment  of  the  mucous  membrane  may  be  found  not 
diseased.  And  instead  of  this  regular  form,  the  disease  may  be 
situated  at  different  points;  that  is,  there  is  interruption  in  its 
continuity.  The  disease  is  sometimes  diff'used  over  a  larger 
surface:  sometimes  extending  through  the  whole  extent  of  the 
canal. 

The  epithelioma,  whether  on  a  small  or  large  scale,  tends  to 
narrow  the  oesophageal  canal;  and  this  stenosis  is  greatest  when 
the  neoplasm  exists  in  narrow  circular  form;  for  then  the 
disease  reaching  the  iimer  circular  muscular  fibres,  shortens 
them.  The  disease  having  involved  the  entire  thickness  of  the 
wall  may  invade  structures  contiguous.  Ulceration  appearing  in 
the  surface  of  the  affected  structure,  the  stenosis  is  lessened,  and 
the  functional  trouble  seemingly  diminished.  The  extension  of 
the  disease  to  neighboring  parts  may  so  fix  the  oesophagus, 
through  adhesions,  that  the  movement  of  swallowing  is  impeded : 
solid  food  may  lodge  and  afterwards  be  regurgitated.  Also, 
from  prolonged  sojourn  at  one  point,  the  alimentary  matter  vaay 
produce  erosion:  or  cause  an  extension  of  the  ulceration,  which 
already  exists.  By  penetration  througli  the  wall,  an  opening 
may  be  made  into  the  trachea,  bronchus,  pleural  or  pericardial 
cavity;  such  penetration  must  soon  end  the  patient's  life;  and 
life  would  end  most  speedily  if  the  ulceration  extended  to  and 
opened  the  aorta.  Above  the  narrowed  point  there  is  dilatation : 
due  to  the  collection  and  accumulation  of  the  ingested  material 
above  the  strictured  part. 

Metastatic  propagation  of  the  disease  has  been  observed, 
according  to  Petri,  in  nearh'  sixty  percent  of  the  cases;  thus  the 


994  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

disease  lias  reappeared  in  the  glands  which  had  anatomical  con- 
nection with  the  diseased  site;  and  it  has  been  seen  in  much  more 
distant  situations:  viz.,  in  the  lungs,  liver,  brain  and  bones. 

The  remote  reappearance  of  the  disease  in  glands,  as  well  as 
in  non-glandular  structures,  has  been  underrated ;  and  according 
to  Zenker,  metastatic  development  is  oftenest  in  the  tracheal, 
bronchial  and  epigastric  glands.  If  the  disease  be  in  the  upper 
third  of  the  iiesopliagus,  the  cervical  glands  may  be  implicated; 
the  glands  wliicii  are  especially  infected  are  those  situated  near 
the  bifurcation  of  the  carotid  artery;  also,  the  glands  which  lie 
above  and  near  the  clavicle,  on  the  constituent  nerve  trunks  of 
the  brachial  })lexus.  Such  swollen,  indurated  gland,  like  an 
index,  points  to  the  cancer,  and  its  situation  in  the  a3sophagus. 

The  general  symptoms  of  cancer  in  the  oesophagus  vary  in 
different  patients:  some  emaciate  and  present  poor  health  with- 
out marked  local  symptoms;  in  others  the  stenosis  is  the  leading 
symptom.  The  pain  is  variable;  its  site  is  not  so  fixed  that  the 
surgeon  can  locate  the  cancerous  point  through  the  pain,  since, 
often,  the  chief  symptom  is  a  disagreeable  feeling  at  the  pit  of 
the  stomach. 

Betz,  in  1853,  gives  the  following  as  signs  indicative  of  epi- 
thelial cancer  in  the  oesophagus:  when  the  disease  is  at  the  lower 
end,  there  is  pain  near  the  ensiform  cartilage,  or  in  the  pra^cordia; 
but  if  in  the  u})per  part,  then  the  pain  will  be  in  the  throat;  and 
in  the  middle  portion,  the  pain  will  be  felt  in  the  middle  of  the 
chest.  But  if  the  entire  canal  be  affected,  then  there  will  be  the 
sense  of  a  hot  cord  stretched  from  the  throat  to  the  stomach. 
Pain,  wherever  it  may  be,  is  awakened  and  increased  by  swallow- 
ing. Betz  found  the  cancer  in  its  structure  to  be  medullary  or 
fasciculated. 

Ziemssen  finds  that  the  pain  from  oesophageal  cancer  is  more 
severe  at  night.  The  canal  becoming  stiffened  in  its  walls,  and 
likewise  narrowed,  the  difficulty  of  swallowing  soon  results. 
There  is  muscular  unrest  of  the  part,  and  the  patient  makes 
continuous  efforts  to  swallow;  or  there  is  a  retrograde  action  of 
the  parts,  manifested  in  retching  and  regurgitation.  According 
to  the  site,  the  symptoms  will  vary;  if  the  disease  be  situated  low 
down,  a  considerable  dilatation  ma}'  take  place  above  the  nar- 
rowed portion,  in  which  the  solid  ingesta  may  find  lodgment; 
and  then  the  retained  content  may  only,  now  and  then,  be 
rejected.  In  the  regurgitated  material  there  is  seen  a  thick 
gelatinous  mucus, — a  secretion  from  the  irritated  glands;  and 
this  has  been  compared  to  thickened  milk. 


MALIGNANT  GROWTHS  IN  PHARYNX  AND  (ESOPHAGUS.  995 

After  the  epitlieliomatous  disease  has  lasted  some  time,  and 
has  caused  abnost  entire  closure  of  the  canal,  there  may  occur 
extensive  disintegration  and  sloughing,  by  which  the  canal  is 
reopened,  and  the  calibre  so  restored  that  deglutition  becomes  eas}?-, 
and  the  patient  is  cheered  with  the  temporary  illusion  that  his 
disease  has  vanished. 

The  recurrent  nerve  which  lies  close  to  the  oesophagus  may 
be  implicated  in  the  growth,  and  thus  the  laryngeal  muscles,  on 
one  or  both  sides,  may  be  disturbed  in  their  function:  a  condi- 
tion revealed  by  the  suppressed  or  altered  voice. 

The  sound  can  aid  in  determining  the  fact  that  the  canal  is 
obstructed,  or  narrowed.  Any  instrument,  whether  used  for 
exploratory  or  alimentary  purposes,  must  be  introduced  with 
cautious  care;  for  the  unseen  point  may  stray  from  its  proper 
route,  and  a  false  passage  be  bored  into  the  wall.  Surgical 
history  abounds  in  accidents  of  this  kind;  and  the  swallowing  of 
food,  by  the  victim  of  such  false  passage,  has  precipitated  the 
death  which  the  cancer  was  more  slowly  bringing. 

Matters  vomited,  or  caught  in  the  ear  of  the  sound,  subjected 
to  microscopic  study,  may  furnish  additional  proof  of  the  presence 
of  cancer. 

Tlie  dry,  swarthy  skin  of  the  patient,  his  rapid  emaciation, 
reaching  to  the  extreme  of  corporeal  waste,  the  sunken  abdom- 
inal wall,  through  which  can  be  seen  and  felt  the  contained  vis- 
cera, are  symptomatic  accompaniments  of  epithelial  cancer  of  the 
oesophagus;  and  these  are  the  visible  expression  of  continued 
hunger,  and  progressing  cancerous  infection.  The  patient's  scanty 
food  is  vitiated  by  the  ichorous  excreta  of  his  disease. 

The  regurgitated  matter  can  easily  enter  the  air-passages,  and 
become  the  cause  of  profuse  bronchial  discharge,  and  finally, 
ichorous  pneumonia:  a  complication  which  will  soon  end  life. 
In  some  reported  cases,  an  opening  has  occurred  into  the  pleural 
or  pericardial  cavities,  with  speedy  death. 

If  unrelieved,  the  subject  of  oesophageal  cancer  dies  within 
two  years;  Mackenzie  places  the  average  duration  of  the  disease 
at  eight  months.  The  author,  who  has  seen  a  number  of  cases, 
would  place  the  medium  duration  at  not  less  than  one  year;  and 
as  the  time  w^hen  the  disease  began  is  alwa3's  unknown,  it  is 
probable  that  the  disease  has  a  longer  duration  than  the  figures 
here  given. 

Epithelial  cancer  in  the  oesophagus  occurs  oftenest  in  persons 
at  the  middle  period  of  life;  according  to  Mackenzie,  the  average 


096  PlIAKY.\(ii:AI.    AND    a:S01>n AGKAL    NEOPLASMS. 

period  ill  man  is  about  fift3'-two  and  a  half  years;  in  woman, 
forty-five  and  a  half  years.  In  forty-four  cases  seen  in  Berhn, 
only  three  were  females. 

The  reason  for  the  greater  frequency  in  man  may  be  found 
in  his  habits  of  drinking  stimulating  drinks  :  also  his  irregularities 
in  eating  food  rapidly,  or  too  hot.  The  subject  of  chronic  dys- 
pepsia is  predisposed  to  cancer  in  the  oesophagus,  througii  the 
frequent  eructations  of  acid  or  irritating  matters  from  the  stom- 
ach. Chronic  catarrhal  affection  of  the  ce.'^ophagus  or  stomach 
favors  cancerous  development.  A  scar  which  has  altered  the 
form  of  the  canal,  and  which  impedes  swallowing,  furnishes  the 
leading  causal  element  in  the  evolution  of  cancer,  viz.,  continuou  ; 
irritation. 

The  disease  is  one  which  appeals  most  strongly  for  aid  to  the 
hands  of  the  surgeon :  for  unrelieved,  it  slowly  and  surely 
destroys  life  ;  yet  surgery  with  all  its  advances,  can  only  offer  uncer- 
tain relief.  Epithelioma  here,  as  at  the  threshold  of  the 
alimentary  canal,  is,  for  a  period,  a  purely  local  affection  ;  and  if 
so  situated  that  it  can  be  wholly  excised,  a  cure  may  be  safely 
reckoned  on.  Unfortunately,  the  lower  portion  of  the  oeso|>hageal 
canal  is  so  located  that  disease  there  has  a  safe  refuge  from  the 
surgeon's  knife.  Though  the  walls  of  the  thorax  have  been 
opened,  and  its  interior  with  imi»unity  invaded,  yet  no  hand  has 
yet  had  the  hardihood  to  lay  bare  the  oesophagus  in  tliis  recon- 
dite site,  and  make  it  the  subject  of  operative  attack.  But  when 
the  di.sease  is  situated  in  the  upper  portion  of  the  canal,  it  is 
within  reach  of  some  curative  procedure,  which  may  be  cauteriza- 
tion or  excision.  Excision  is  the  preferable  method.and  this  might 
possibly,  if  the  disease  were  high  in  the  canal,  be  done  through 
the  mouth;  a  better  way  is  to  open  a  route  from  the  outside,  and 
remove  the  part  when  brought  openly  before  the  eye.  Such  an 
operation  was  ])roj)Osed  by  Billroth,  in  1870;  but  was  done  at  a 
later  [)eriod  by  Czerny.  As  preparatory  work  to  oesophageal 
excision,  Czerny  first  did  the  experiment  of  oj)erating  on  a  dog: 
he  removed  two  inches  from  the  cesoj)hagus,  and  stitched  the 
inferior  part  of  the  canal  in  the  cervical  wound.  A  sound  was 
occasional!}"  passed.  The  dog  was  soon  allowed  to  take  food  by  his 
mouth;  but  deglutition  was  not  wholly  satisfactory,  since  not 
long  afterwards,  a  large  piece  of  food  lodged  in  the  pharynx,  and 
required  removal.  The  wound  rapidly  healed,  and  to  maintain 
proper  permeability,  a  sound  was  passed  from  time  to  time;  and 
while  the  dilatation  was  continued,  the  dog  swallowed  his  accus- 


MALIGNANT  GROWTHS  IN  PHARYNX  AND  CESOPHAGUS.  907 

tomed  food,  and  remained  well  nourished.  Later,  the  dog  was 
killed,  and  there  was  found  remaining  a  scar,  which  was  not 
more  than  a  half  line  broad,  and  this  could  readily  be  dilated 
and  traversed  by  a  sound. 

This  fortunate  operation  on  the  dog  emboldened  this  ingen- 
ious surgeon  to  make  a  trial  of  the  operation  on  a  woman,  aged 
fifty-one  years,  who  was  the  subject  of  oesophageal  cancer.  For 
this  purpose,  on  the  left  side  of  the  trachea,  Czerny  made  a  cut 
from  the  hyoid  bone  to  near  the  sternum,  along  the  inner  border 
of  the  sterno-cleido-mastoid  muscle.  The  omo-hyoid  muscle  was 
severed;  and  the  thyroid  vessels,  which  were  encountered,  were 
caught,  doubly  tied  and  divided.  The  diseased  oesophagus  fortu- 
nately had  contracted  no  adhesions  to  the  contiguous  parts. 
There  was  removed  about  two  and  a  half  inches  of  the  oesopha- 
gus, which  was  the  site  of  a  cancerous  growth,  of  circular  form. 
The  inferior  portion  of  the  canal  was  brouglit  into  the  wound  and 
fixed  to  the  skin  by  eight  sutures;  a  soft  catheter  was  inserted 
into  this,  and  the  patient  fed  through  this  tube.  The  wound 
healed  rapidly,  and  some  months  after  the  operation,  the  woman 
recovered,  and  was  able  to  do  her  accustomed  work.  The  patient 
preferred  to  retain  the  fistula,  rather  than  to  have  an  attempt 
made  to  restore  the  continuity  of  the  canal. 

Czerny  has  demonstrated  by  his  work  that  a  portion  of  the 
oesophagus  can  be  excised:  and  hence,  such  an  exsection  is 
indicated  in  cases  in  which  the  cancerous  disease  is  limited  to  an 
accessible  portion  of  the  canal.  For  example,  if  the  affection  be 
insulated  or  circular  in  site;  but  if  it  be  diffused  over  an  extensive 
tract  of  the  canal,  then  such  excision  would  be  impracticable. 
Also,  if  the  larynx  were  implicated,  the  exsection  of  the  air- 
passage  and  the  cesoj)hagus  would  be  a  formidable  or  impossible 
operation.  And  whatever  the  site  or  extent  of  the  disease  might 
be,  as  long  as  deglutition  were  possible,  the  patient  would  reluc- 
tantly consent  to  an  operation,  which  would  exchange  the  site  of 
entrance  of  his  aliment  from  the  mouth  to  an  opening  in  tlie  side 
of  the  neck.  An  operation  to  be  effective  should  be  done  early: 
a  condition  too  often  excluded  through  the  patient's  preferring  to 
abide  with  evils  with  which  he  is  familiar  rather  than  to  take 
refuge  in  those  unknown.  And  to  this  hesitancy  may  often  be 
referred  the  lack  of  success  of  the  deferred  operation  :  for  if  tlie 
powers  of  repair  are  nearly  exhausted,  tlie  surgeon's  wound  may 
only  be  an  added  factor  in  the  destruction  of  life. 

In  the  cases  unfitted  for  total  excision  of  tlie  affected  portion 


998  PHARYNGEAL    AND    (ESOPHAGKAL    NEOPLASMS. 

of  the  oesophagus,  it  may  still  be  possible  sometimes  to  open  the 
occluded  canal,  so  that  a  tube  for  nutrition  may  be  introduced, 
and  tl)e  patient  thus  fed:  thus  a  brief  reprieve  from  impending 
death  may  be  obtained. 

In  cases  unsuited  for  resection,  by  the  prudent  use  of  the 
sound,  the  closed  canal  has  been  reopened,  so  that  normal  deglu- 
tition was  possible  for  a  short  time;  in  such  dilatation,  force  must 
be  avoided,  and  the  fatal  consequences  of  a  false  passage  must  be 
borne  in  mind. 

If  the  closure  of  the  oesophagus  be  in  the  tliorax,  then  life 
may  be  prolonged  by  the  use  of  a  gastric  fistula,  through 
which  food  can  be  introduced.  The  work  done  in  this  field  by 
Sydney  Jones,  Schonborn  and  Verneuil  has  shown  that  it  is. 
possible  to  form  a  mouth  directly  into  the  stomach,  and  that  life 
thus  may  be  prolonged.  As  a  rule,  the  respite  gained  has  been 
so  brief,  that  many  authorities  are  undecided  as  to  the  value  of 
the  procedure.  A  patient  seen  by  the  writer,  on  whom  gastros- 
tomy was  performed  by  Verneuil,  was  an  example  of  the  benefit 
of  the  procedure,  in  a  properly  selected  subject;  the  patient  was  a 
youth,  who  was  in  good  health  in  every  way,  except  that  his 
ffisophagus  was  occluded  by  a  neoplasm;  this  young  man 
received  permanent  relief  from  gastrostomy. 

Wounds  of  the  (Esophagus. — Among  the  wounds  of  the  oesoph- 
gus  must  be  mentioned  those  of  which  the  surgeon's  knife  has  been 
the  cause:  as  in  resection  of  the  canal,  or  oesophagotomy,  done 
from  the  inside  or  outside.  And,  again,  this  canal  has  inadvert- 
ently been  opened  in  tracheotomy,  in  which  the  knife  wandered 
from  its  tracheal  field,  and  implicated  the  oesophagus. 

The  accident  of  opening  tlie  oesophagus  in  tracheotomy  is  apt 
to  occur  in  cases  in  which  there  has  been  much  haste  in  opening 
the  trachea:  as  may  be  demanded  in  the  subject  who  is  moribund 
from  asphyxia  arising  from  closure  of  the  air-passage.  Also,  if 
tracheotomy  be  done  by  one  stroke,  instead  of  by  successive 
steps  of  dissection,  there  is  danger  that  the  knife  will  reach  the 
subjacent  oesophagus:  such  an  error  can  only  be  shunned  by  the 
experienced  and  well-disciplined  hand.  Where  this  accident 
has  occurred,  to  prevent  the  entrance  of  materials  from  the  oesoph- 
agus into  the  trachea,  the  patient  should  be  fed  through  a  tube 
reaching  to  a  point  beyond  the  wound.  This  tube  should  pass 
through  the  inferior  nasal  meatus,  and  be  fixed  permanently  in 
its  site.  Wounds  may  be  inflicted  by  an  assailant,  or  by  the 
subject  himself:  and  such  may  be  large,  in  which  the  oesophagus 


WOUNDS    OF    THE    (i:SOPHAGUS.  999 

is  wholly  or  partly  divided ;  or  it  may  be  a  small  penetrating 
wound.  When  small,  the  escape  of  mucus  and  saliva  would 
denote  perforation  of  the  canal;  and  in  a  large  wound,  the  char- 
acter Avould  be  evident  to  sight  and  touch. 

The  treatment  of  a  large  w^ound  usually  consists  in  partial 
closure  by  suture,  and  alimentation  through  an  oesophageal 
tube;  but  the  small  wound  should  be  completely  sutured,  and 
the  patient  afterwards  fed  through  a  tube. 

Gunsliot  wounds  involving  the  oesophagus  were  the  subject  of 
study  by  Wolzendorf  in  1880;  of  one  hundred  and  forty-five 
wounds  seen  by  him  the  most  were  produced  by  the  gunshot 
missile.  In  eiglit  cases,  the  external  jugular  vein  was  wounded, 
the  internal  jugular  once,  and  the  carotid  artery  in  five  cases. 
The  spinal  canal  and  cord  were  injured  in  three;  and  in  three 
others,  the  brachial  plexus  was  wounded.  In  seven  cases,  the 
windpipe  was  opened  to  save  life,  and'in  but  one  patient  was  this 
successful. 

Pernicious,  or  ichorous  suppuration  may  arise  from  opening 
the  posterior  wall  of  the  oesophagus.  Fifty-two  cases  of  such 
wounds  have  been  recorded :  ichorous  pneumonia  was  thus 
caused;  and  six  patients  died  from  this  complication. 

Wolzendorf  finds  that  gunshot  wounds  of  the  oesophagus  are 
twice  as  frequent  as  incise^  wounds:  death  from  the  former 
occurred  in  forty-four  and  two-tenths  per  cent  of  the  cases;  but 
from  the  latter  twenty-two  and  five-tenths  per  cent  died. 

Stricture  occurs  oftener  after  gunshot  wounds  than  after 
incised  ones;  yet  fistula  oftener  follows  the  incised  wounds. 

When  the  oesophagus  is  entirely  severed,  mortality  is  twice 
as  great  as  when  the  canal  is  but  partially  divided.  And  cases 
in  which  the  thyroid  cartilage  is  also  wounded,  are  much  more 
dangerous  than  those  confined  to  the  oesophagus. 

Death  from  such  wounds  is  caused  most  frequently  by  suffo- 
cation; yet  it  may  come  from  general  exhaustion.  The  fatal 
result  can  be  accelerated  by  emphysema  of  the  mediastinum, 
swelling  of  the  larynx,  or  the  entrance  of  fluids  into  the  air- 
passages;  and  finally,  haemorrhage,  or  palsy  of  the  vagus,  may 
destroy  life. 

The  local  treatment  consists  in  arresting  the  bleeding,  pro- 
viding for  respiration,  nutrition  and  the  escape  of  the  excreted 
matters.  One  should  not  attempt  complete  closure  of  the  wound, 
eitlier  of  the  oesophagus  or  larynx  ;  3^et  Wolzendorf  advises  par- 
tia   closure:  and  for  this,  he  employs  deep  sutures;  and  such  deep 


lUU"  PHAHYNGEAL    AXI>    (ESOPHAGEAL    NEOPLASMS. 

fetitch  should  include  both  the  oesophagus  and  air-passage,  if 
these  both  be  wounded.  If  the  (esophagus  be  wholly  severed, 
and  the  ends  not  freely  movable,  then  one  may  loosen  the 
ends,  and  approximate  them  by  looped  threads  attached  to  the 
ends. 

During  the  treatUR-nt  of  lh<."  (esophageal  wound,  the  nutrition 
may  be  maintained  tlirough  the  rectum  by  nutrient  injections; 
and  as  the  wound  sonutimes  has  healed  in  a  few  days,  the  entire 
nourishment  may  be  introduced  in  this  way.  Should  the  period 
of  healing  be  prolonged,  then  Wolzendorf  would  not  depend  on 
rectal  nutrition,  but  lie  would  introduce  a  tube  through  the 
mouth ;  and  if  this  could  not  be  done,  tlien  it  should  be  passed 
through  the  wound,  and  permitted  to  remain  in  the  canal,  for 
some  time.  Nutrition  was  less  embarrassed  by  the  gunshot  wound 
than  by  the  incised  one. 

In  cases  in  which  nutrition  cannot  be  maintained  by  the  rec- 
tum, nor  by  means  of  a  tube  passed  through  the  mouth  or  the 
wound,  then  an  opening  should  be  made,  lower  down,  into  the 
(Desophagus,  and  a  tube  introduced  tliere. 

The  usual  result  of  wounds  of  the  cesophagus  is  narrowing  of 
the  normal  calibre;  to  prevent  this,  a  resort  should  be  had  to 
dilating  sounds,  which  will  counteract  the  tendency  to  stenosis. 
The  daily  use  of  such  sotmds  should  be  continued,  until  the 
tendency  to  contraction  has  ceased:  a  period  usually  reaching 
through  several  months. 

TRACHE(JT0MY;    BKoNfPKJTOMV. 

Many  generations  of  physicians  and  surgeons  have  read  and 
adopted  the  writings  of  Hippocrates  as  articles  of  faith  which 
should  not  be  questioned  ;  unfortunately  for  the  advance  of  Me(,li- 
cine,  these  doctrines  contained  some  serious  errors:  as  an  exam- 
ple of  this  may  be  cited  the  apliorism  in  which  it  is  stated  that 
section  of  cartilage  or  bone  will  not  be  repaired.  And  this  erron- 
eous belief  retarded  surgical  advance,  since  it  condemned  as  in- 
curable, cases  in  Mhicli  interference  with  these  structures  was  de- 
manded. For  wlio  would  venture  to  wound  cartilage,  if  such 
wound  would  not  heal?  Men,  however,  had  eyes,  and  wounds  of 
tliese  structures  came  under  their  observation,  in  which  repair 
did  take  place ;  but  the  error  was  planted  so  firmly  by  the  Father  of 
Medicine,  that  the  hands  of  many  generations  of  medical  men 
were  required  to  pluck  it  up,  and  to  plant  in  its  place,  the  fact  that 
cartilage  when  wounded  will  heal.     The  studies  of  Goodsir,  Vir- 


tkacheotomy;  bronchotomy.  1001 

chow  and  Billroth  have  discovered  that  the  repair  is  mainly  ac- 
complished by  cells  that  are  the  offspring  of  the  maternal  tissue. 

The  trachea  was  opened  long  before  the  knowledge  had 
been  gained  that  cartilage,  when  divided,  would  reunite;  yet  the 
work  was  so  done  as  to  avoid  the  cartilaginous  element  of  the 
tracheal  wall.  Thus  Paul  of  JEgma,  in  the  fourth  century, 
relates  that  Antyllus  opened  the  trachea  for  relief  where  suffoca- 
tion was  impending,  or  a  foreign  body  had  entered  the  air- 
passages  :  and  his  plan  was  to  make  a  transverse  incision,  between 
the  third  and  fourth  tracheal  rings.  In  thus  cutting,  the  carti- 
lage was  spared.  The  sudden  exit  of  the  air,  and  the  extinction 
of  the  voice,  proved  that  the  air-canal  liad  been  opened.  The 
wound  was  maintained  open  by  means  of  two  hooks.  As  soon 
as  the  patient  could  breathe  easily,  the  wound  was  closed  by 
sutures. 

From  the  time  of  Paul  of  ^gina  to  the  sixteenth  century,  one 
finds  in  the  annals  of  medicine,  references  to  this  operation  of 
Antyllus;  the  Arabians,  as  Avicenna,  and  the  early  French  sur- 
geons, also  mention  it;  but  it  appears  to  have  only  been  resorted 
to,  in  cases  of  emergency,  in  which  life  was  imperiled  by  impend- 
ing suffocation. 

The  operation  was  done  by  the  Italian  surgeons  in  the  six- 
teenth century.  .  Fabricius  d'Aquapendente  operated  by  first 
making  a  vertical  cut  through  the  skin;  then  he  entered  the 
tracliea  transversely  between  two  rings.  He  used  a  canula  to 
permit  the  passage  of  air,  and  his  pupil  Casserius  gave  the 
canula  a  curved  form;  and  he  held  this  in  place  by  cords  which 
passed  around  the  neck.  In  the  latter  part  of  the  sixteenth  cen- 
tury Sanctorius,  of  Padua,  made  the  opening  into  the  air-canal 
by  means  of  a  trocar,  which,  being  thrust  in,  the  ensheathing 
canula  was  left  in  place. 

In  the  seventeenth  century  the  operation  was  done  in  Ger- 
many, France,  Italy  and  Portugal.  In  France  it  was  done  by 
Habicot  on  a  boy  who  had  swallowed  coin;  and  to  save  his  life, 
the  trachea  M^as  opened. 

In  the  eighteenth  century  there  were  two  methods  pursued 
in  the  work:  in  one  the  operation  was  done  by  a  trocar,  which 
was  plunged  into  the  trachea  at  one  thrust;  thus  Richter  and 
Decker  operated,  and,  as  will  later  be  seen,  this  old  plan  of  Sane 
torius  has  had  its  advocates  in  the  nineteenth  century.  But  as 
anatomy  was  more  studied,  and  operative  work  became  more 
accurate  and  adroit  through  preliminary  exercise  of  the  hand  on 
64 


1002  rHAUYXGKAL    AND    CESOPHAGEAL    XEOl'LASMS. 

the  cadaver,  then  the  surgeon  ])referrcd  to  open  the  air-passage 
bv  methodical  dissection ;  and  then,  the  fear  haviuir  been  dis- 
xjardc'd  that  wounded  cartihige  woukl  not  heal,  a  vertical  incision 
was  l)o]<lly  made  through  the  anterior  wall  of  the  trachea.  And 
the  error  taught  by  Hippocrates  ceased  to  exist  after  its  long 
course  through  the  centuries:  a  circumstance  which  finds  a  sem- 
blance in  the  two  great  rivers  of  the  Western  World,  of  which 
the  clear  waters  of  the  one  receiving  the  turljid  waves  of  the 
other,  the  current  of  the  two  remains  clouded  afterwards,  and 
the  turbid  pollution  of  the  water  only  vanishes  wlien  the  great 
stream  has  traversed  a  continent:  a  lesson  to  medical  or  surgi- 
cal authority  to  avoid  adding  perturbing  error  to  the  ever 
changing  and  yet  enduring  course  of  our  venerated  science. 

Tlie  operation  was  originally  named  bronchotomy,  but  in  the 
eigthteenth  century  it  was  given  the  name  of  tracheotomy, 
which  name  gradually  superseded  the  older  one. 

The  single  canula  was  used  for  a  long  time;  a  double  one 
was  introduced  by  jMartin,  which  device  offered  the  advantage 
that  when  one  canula'was  removed  the  other  remained  in  place. 

Despite  the  brilliant  successes  which  were  obtained  through 
the  operation,  it  did  not  become  popular  until  Louis,  an  eminent 
authority,  wrote  a  monograph  on  the  subject,  which  tended  to 
generalize  the  procedure.  Louis  claimed  that  in  some  cases  the 
operator  had  not  penetrated  the  tracheal  canal ;  and  that  this 
fatal  mistake  was  not  confined  to  Louis'  times,  but  is  sometimes 
committed  to-day,  lies  within  the  writer's  observation. 

Tiie  operation  was  first  done  for  the  purpose  of  removing 
foreign  bodies,  which,  having  entered  the  air-|)assages,  caused 
suffocation ;  later,  tracheotomy  was  done  for  relief  in  cases  in 
which  asphyxia  was  induced  by  other  causes:  for  example,  by 
fracture  of  tlie  larynx,  or  in  wounds  of  the  throat  which  led  to 
tumefaction  and  closure  of  the  air-canal.  In  the  eighteenth  cen- 
tury the  sphere  of  the  operation  was  yet  further  widened  through 
its  employment  for  relief  of  suffocation  originating  in  anginous 
disease  of  tlie  throat.  Thus  in  cynanche  trachealis,  to-day  desig- 
nated croup,  it  was  proposed  by  Home  to  open  the  trachea,  and 
thus  permit  ingress  of  air  below  the  site  of  the  occluding  disease. 

•Such  an  operation  was  successfully  done  by  John  Andrew, 
in  London,  in  1782.  The  operation  at  first  found  but  few  advo- 
cates; in  fact,  though  advocated  by  Crawford,  Stoll  and  other 
eminent  authorities,  it  was  generally  0[)posed.  Tracheotomy, 
for  relief  in  croup,  found  in  the  nineteenth  century  earnest  advo- 


tracheotomy;  bronchotomy.  1003 

cates  in  Bretonneaa  and  Trousseau,  in  France,  and  in  Pitha, 
Roser,  Langenbeck  and  Hueter,  in  Germany;  the  greatest  credit 
is  due  to  Trousseau,  whose  able  pen  pleaded  eloquently  for  it,  and 
whose  scalpel  achieved  a  success  for  the  operation,  which  place 
it  among  the  truly  life-saving  procedures;  and  as  tracheotomy 
is  usually  done  on  the  young  subject,  surgery  is  able  to  point 
with  satisfaction  to  achievements  here  in  which  many  ^^ears  of  ' 
existence  are  given  to  the  rescued  patient. 

In  recent  times  tracheotomy  has  obtained  a  still  wider  sphere 
of  application.  An  enumeration  of  the  various  cases  in  which 
the  operation  may  be  resorted  to  as  a  remote  aid,  or  as  one  at 
once  necessary  to  save  life,  are  the  following : — 

1.  Foreign  bodies  which  have  entered  tlie  air-passages,  and 
which,  unremoved,  will  destroy  life. 

2.  Scalding  from  steam,  hot  water,  or  an  acid  or  alkaline 
solution,  which  cauterizes  or  destroys  the  mucous  surface  with 
which  it  comes  in  contact. 

3.  Injuries  of  the  larynx,  as  fracture  of  the  thyroid  or  cricoid 
cartilage,  fracture  of  the  os  hyoides;  also,  for  relief  after  incised, 
lacerated,  or  gunshot  wounds  of  these  parts. 

4.  Inflammatory  or  cedematous  processes  in  which,  through 
cell-growth  or  local  hypersemia  of  the  parts,  the  air-passage  is 
rendered  too  narrow  for  the  transit  of  air  in  respiration.  An 
abscess  at  the  entrance  of  the  larynx  or  in  the  cervical  structures, 
so  situated  as  to  compress  the  air-canal,  may  demand  tracheot- 
omy to  save  life.  Likewise,  a  neoplasm,  benign  or  malignant, 
by  encroachment  on  the  air-canal,  may  lessen  its  calibre  and 
become  an  indication  for  the  operation. 

5.  (Edema,  or  inflammation  in  the  lower  jDart  of  the  trachea, 
may  so  narrow  the  canal  that  a  sufficient  amount  of  air  cannot 
be  received  to  maintain  life;  through  an  opening,  made  into  the 
upper  part  of  the  trachea,  air  may  be  admitted,  and  a  way 
opened  by  which  the  affected  part  can  be  reached  and  treated. 

6.  In  cases  of  apparent  death  from  an  anjesthetic  or  from 
hanging,  submersion  in  water  or  other  asphyxiating  medium, 
tracheotomy  furnishes  the  most  direct  route  by  which  air  can 
be  introduced  into  the  lungs.  Also,  when  apparent  death  has 
arisen  from  immersion  in  carbonic  acid  or  other  asphyxiating 
gas,  then  a  tracheal  opening  furnishes  the  shortest  way  by  which 
air  can  reach  the  lungs  for  restoration  of  the  patient. 

7.  Laryngeal  and  tracheal  stricture  from  some  chroniq  mor- 
bid process  seated  in  the  wall  of  the  air-passages  may  require 
tracheotomv. 


1(»(»4  PIIAKYXGEAL    AND    QvSOPH AGF:AL    XEOl'LASMS. 

8.  Tracheotomy  ma}'  be  dcniaiulcd  by  aneurism  or  by  .some 
body  lodged  in  the  ceso[)hagus. 

9.  Neophism  springing  from  the  inner  wall  of  tlie  trachea  or 
larynx  may  be  reached  by  tracheotomy. 

10.  Ill  palsy  of  tlie  recurrent  nerves  which  supply  motor 
innervation  to  the  muscles  whicli  maintain  the  glottis  open,  the 
operation  may  be  done. 

11.  As  a  preparatory  act  to  some  operation  on  the  pharynx 
or  larjmx,  or  as  an  aid  in  the  removal  of  growths  from  the  neck, 
tracheotomy  is  sometimes  preliminarily  performed. 

12.  Croup  and  diphtheria:  for  the  relief  of  the  patient  suffo- 
cating from  these  diseases,  tracheotomy  is  oftenest  resorted  to;  and 
under  this  head  the  instrumental  apparatus  for,  as  well  as  the 
methods  pursued  in,  tiie  operation  of  tracheotom}'  will  be  fully 
considered. 

Foreign  bodies  in  the  air-passages:  this  accident  has  been 
treated  of,  and  it  remains  here  to  say  that  after  the  non-operative 
means  have  been  fruitlessly  tried,  then  tracheotomy,  or  laryngot- 
omy,  as  the  case  may  indicate,  should  not  be  deferred.  Prompt- 
ness, and  not  delay,  should  be  the  rule  of  action  ;  for  by  procras- 
tination the  foreign  agent  may  irritate  and  inflame  the  parts 
with  which  it  lies  in  contact;  and,  besides,  during  the  lodgment, 
the  subject  is  deprived  of  the  normal  amount  of  air. 

Scalding  from  steam,  hot  liquid,  or  the  swallowing  of  acids, 
alkalies  or  other  escharotic  agents:  the  injury  from  any  of  the 
agencies  here  named  may  excite  an  oedema  or  inflammatory 
swelling  of  the  interior  of  the  larynx,  which  may  suddenly  close 
the  glottis  and  cause  death  ;  in  such  emergency,  if  suffocation 
seems  imminent,  tracheotomy  should  be  resorted  to;  and  a 
canula  being  introduced  must  be  worn  until  the  patient  lias 
recovered  from  the  effects  of  the  injury.  And  sliould  the  injury 
have  been  inflicted  by  an  escharotic  agent  which  can  be  neutral- 
ized by  some  counter  agent,  then  the  tracheal  opening  will  serve 
as  a  way  by  which  the  corrective  means  can  be  introduced:  thus 
oil  may  enter  and  check  the  destructive  alkali ;  or  an  inert 
alkali  may  arrest  the  action  of  an  acid.  And  should  subsequent 
stricture  impend  through  cicatricial  contraction,  then  the  surgeon 
must  not  be  in  haste  to  remove  the  canula,  but  this  must  remain 
in  place,  while  the  mechanical  treatment  is  being  carried  out,  to 
prevent  the  formation  of  a  stricture,  or  for  the  removal  of  a 
stricture  already  formed.  Such  treatment  consists  in  the  occa- 
sional introduction  of  graduated  sounds  into  the  larynx  or  trachea, 


tracheotomy;  broxchotomy.  1005 

as  the  case  may  demand.  If  it  be  probable  that  the  heat  or 
escharotic  has  penetrated  below  the  larynx,  then  the  opening- 
should  be  made  as  low  as  possible  in  the  trachea.  The  tracheal 
opening  may  sometimes  be  utilized  for  the  admission  of  instru- 
ments in  the  treatment  of  the  stricture. 

Injuries  of  the  larynx,  as  fracture  of  its  component  cartilages, 
with  or  without  fracture  of  the  hyoid  bone,  may  so  close  the  air- 
passages  that  death  may  speedily  occur.  Gurlt  has  collected 
a  series  of  forty-two  cases  of  such  injury ;  in  the  most  of  these, 
the  larynx  alone  was  fractured;  yet  in  a  small  number,  along 
with  this  there  was  also  fracture  of  tlie  hyoid  bone,  or  of  the 
trachea.  Death  occurred  in  nearly  all  these  patients  in  whom 
tracheotomy  was  not  performed.  Hunt  has  reported  twenty- 
seven  cases  of  such  fracture,  of  whom  seventeen  died,  ten  recov- 
ered, and  in  six  of  the  latter  tracheotomy  was  performed. 
Durham  has  collected  a  series  of  sixty-two  cases  of  such  injury, 
of  whom  fifty  died;  only  twelve  recovered,  and  in  eight  of  the 
recoveries  tracheotomy  was  performed. 

A  result  of  such  injury  is  dislocation  of  the  fragments,  caus- 
ing occlusion ;  or  there  may  be  effusion  of  blood  in  the  submucous 
tissue,  and  swelling,  which  closes  the  canal.  Or  the  fracture  may 
lacerate  the  mucous  membrane,  and  lead  to  emphysematous 
infiltration  of  the  soft  parts:  in  respiration,  the  inspired  or 
expired  air  being  pumped  into  the  tissues,  until  fatal  occlusion 
of  the  passage  is  produced.  The  facts  stated  show  the  gravity  of 
laryngeal  and  tracheal  fracture;  and  so  greatly  are  the  chances  of 
life  increased  by  tracheotomy,  that  it  has  been  advised  to  perform 
it,  when  the  diagnosis  of  fracture  has  not  been  clearly  established. 
After  the  trachea  has  been  opened,  there  is  offered  an  opportunity 
for  replacing  the  ill-placed  fragments;  also  facility  is  thus  offered 
for  checking  subsequent  strictural  encroachment  of  the  broken 
parts  on  the  canal. 

Langenbeck  counsels  tracheotomy  in  all  cases  in  which  a 
wound  has  been  made  which  involves  the  glottis  or  epiglottis; 
for  such  wounds  may  end  fatally,  as  was  seen  in  the  young- 
assassin  Blind,  who  attempted  to  kill  Bismarck,  and  afterwards 
tried  to  kill  himself  by  thrusting  a  penknife  into  his  neck;  the 
instrument  penetrated  the  base  of  the  epiglottis  and  produced  an 
extravasation  of  blood  into  the  tissues,  which  caused  fatal 
suffocation. 

In  cut-throat,  in  which  the  trachea,  larynx  or  pharynx  is 
wounded,  tracheotomy  is  often  demanded  as  projihylaxis  against 


lOOG 


PHAKYXGEAL    AND    (ESOPHAiiKAL    NEOPLASMS. 


tlie  suffocation  which  may  arise  from  the  Avoiiiid;  for  in  such 
injury,  a  portion  of  the  kiryngeal  wall  may  be  slictd  off,  and  act 
as  a  valve  which  can  close  the  passage,  and  speedily  sulfocate: 
and  the  knife  of  the  suicide  has  done  similar  work  in  splitting 
the  epiglottis,  and  converting  it  into  a  fatal  valve. 

In  case  of  an  incised  wound  that  completely  sunders  the 
trachea,  permitting  the  lower  end  to  bury  itself  in  the  cervical 
structures,  then  the  divided  ends  should  be  reunited,  and  a  canula, 
shown  in  the  subjacent  figure  101,  may  be  inserted  at  the  site  of 


Figure  101.  From  Scliiiller,  showing:  a  canula  tliat  can  be  inserted  in 
sections  a  and  h;  and  M'lien  placed  in  site,  the  sections  can  be  locked,  as  shown 
at  the  left,  abcL 

the  wound;  or,  what  would  be  preferable,  should  the  space  permit 
it,  an  opening  should  be  made  into  the  trachea  below  the  wound, 
and  an  ordinary  canula  inserted  there:  thus  done,  there  would 
be  less  interference  with  the  union  of  the  divided  ends. 

Among  the  indications  given  for  the  performance  of  trache- 
otomy, an  important  one  is  that  under  the  fourth  head,  in  which 
the  air-passage  is  obstructed  by  oedema,  or  some  inflammatory 
process.  (Edema,  in  which  serum  is  effused  beneath  the  mucous 
membrane,  w4ien  situated  in  the  aryteno-epiglottidean  folds  of 
this  membrane,  may  fatally  close  the  entrance  of  the  larynx; 
also,  oedema  invading  the  glottis  itself,  may  early  close  that 
narrow  passage.  The  loose  adherence  of  the  mucous  membrane 
to  the  vocal  chords  is  an  anatomical  condition  which  disposes  to 
serous  accumulation  here,  in  case  the  efferent  veins  of  the  laryn- 
geal or  cervical  structures  are  compressed,  through  some  enlarge- 
ment or  tumefaction.     And    this   causal   agency   is  sometimes 


tracheotomy;  bronchotomy.  1007 

23resent  in  diffuse  pharyngitis  or  tonsillitis,  which  ends  in  suppu- 
ration. Or  such  inflammatory  and  suppurative  process  may 
arise  in  the  tissues  which  lie  outside  of,  but  close  to,  the  larynx; 
such  aifection  not  unfrequently  travels  and  climbs  over  the 
thoroidean  walls,  and  entering  the  cavity  of  the  larjaix,  obstructs 
the  passage. 

Instead  of  arising  passively  through  obstruction  of  the  veins, 
as  simple  oedema,  it  is  probable  that,  quite  as  often,  the  process  is 
an  active  one,  in  which  through  inflammation  a  cell-growth  is 
formed,  which,  as  an  interstitial  element,  adds  to  and  so  thickens 
the  normal  tissues  as  to  diminish  the  normal  calibre  to  a  degree 
that  breathing  is  interfered  with. 

In  tliese  cases,  whether  from  passive  oedema,  or  active  ii:iflam- 
matory  swelling,  tracheotomy  is  given  high  rank  as  a  life-saving 
operation  by  Pitha,  who,  in  1857,  wrote  on  the  subject.  He 
claims  that  it  is  of  signal  service  in  both  oedema  of  the  glottis 
and  laryngeal  stenosis  from  other  cause;  and  that  the  tracheal 
opening  tends  to  dissipate  the  obstruction.  Even  cicatricial 
narrowing  above  the  tracheal  opening  seems  to  gradually  widen. 
And  he  observed  that  where  the  respiration  is  hampered,  the 
tracheal  mucous  membrane,  as  well  as  that  of  the  passage  above, 
becomes  swollen;  in  such  cases,  tracheotomy,  like  a  charm, 
removes  the  turgid  state  of  the  parts,  and  the  cyanosis  from 
venous  blood,  soon  passes  away.  Also,  when,  from  ulcerative 
action  in  the  larynx,  catarrhal  excretion  inenaces  suffocation, 
then  tracheotomy  gives  relief 

If  an  abscess  by  its  pressure  occludes  the  air-passage,  the  former 
should  be  freely  opened;  and  this  will  usually  suffice  for  the 
removal  of  the  dyspnoea;  should  it  not  do  so,  then  the  trachea 
should  be  opened  below  the  constricted  part.  Also  a  tumor, 
lymphomatous,  goitrous,  sarcomatous  or  carcinomatous  in  nature, 
may  encroach  on  the  air-canal  and  diminish  its  calibre;  in  such 
cases  the  difficulty  of  breathing  can  commonly  be  alleviated  by 
extirpating  the  growth;  but  should  the  growth  recur,  then  a 
recourse  must  be  had  to  tracheotomy  for  further  relief 

In  the  cases  here  cited,  an  invariable  rule  for  guidance  can 
scarcely  be  established;  whether  tracheotomy  should  be  per- 
formed will  depend  on  the  amount  of  dyspnoea  that  is  present; 
and,  also,  whether  this  is  increasing  or  lessening;  and  if  it  be 
increasing,  the  surgeon  should  not  delay  to  furnish  relief  by  a 
tracheal  opening,  even  though  the  alleviation  be  transient. 

Another  indication  for  tracheotomv  is  that  in  which  tlie  tra- 


1008  PHAKYNGEAL    AND    (ESOPHAGEAL    NEOPLASMS. 

chea  is  narrowed  below  the  site  where  section  can  be  made,  b}' 
oedematous  or  inflammatory  change,  or  by  the  pressure  of  a 
growth;  in  such  cases,  relief  can  be  given  through  trache- 
otomy which  permits  the  introduction  of  a  long  canula  through 
the  narrowed  canal.  Such  a  canula  may  reach  into  the  chest; 
and  can  maintain  patency  sufficient  for  respiration,  despite  the' 
encroachment  of  the  constricting  agency.  An  example  of  sucli 
use  of  tracheotomy  was  seen  by  the  writer  in  a  case  of  lym- 
phomatous  enlargement  of  the  glands,  in  which  the  neoplastic 
development  involved  the  glands  around  the  trachea  in  the 
upper  part  of  the  mediastinum.  Though  the  disease  was  incura- 
ble in  the  patient  referred  to,  yet  signal  relief  was  obtained  by 
the  operation,  and  life  prolonged. 

Tracheotomy  is  a  means  of  relief  in  cases  of  asphyxiation 
through  chloroform  and  narcotizing  gases;  as  well  as  an  aid  in 
resuscitation  of  those  who  have  been  suffocated  through  sub- 
mersion in  a  liquid  or  semi-liquid  medium,  or  who  have  been 
buried  in  sand,  earth  or  other  pulverulent  material. 

In  a  case  of  apparent  death  from  a  mixture  of  ether  and 
chloroform,  used  as  an  ansesthetic,  the  writer  recalled  the  man 
to  life,  by  rapidly  opening  the  trachea  and  blowing  air  into  tlie 
lungs.  It  was  necessary  to  continue  the  insufflation  of  air  for 
some  time,  before  normal  breathing  was  resumed  by  the  patient. 

An  objection  has  been  offered  against  such  insufflation  of  air 
into  the  lungs,  that  the  thoracic  walls  remaining  .stationary,  there 
is  not  room  for  expansion  of  the  lungs;  and  that  the  air  being 
forced  into  them  would  rupture  the  air-cells.  This  risk  might 
be  avoided,  and  the  work  done  better,  if  insufflation  were  com- 
bined with  artificial  respiration,  done  according  to  Silvester's 
plan;  that  is,  the  air  should  be  blown  into  the  lungs  when  the 
arms  are  U[)lifted,  corresponding  to  the  inspiratory  act;  and  the 
insufflation  should  be  suspended  during  the  expiratory  act  of 
lowering  the  arms,  and  compressing  the  chest.  Done  in  this 
way,  the  air  blown  in  would  not  injure  the  pulmonary  tissue. 
This  procedure  maybe  done  in  all  cases  in  which  there  is  appar- 
ent death  from  a  poisonous  gas,  or  from  suffocation  by  submer- 
sion in  sand  or  some  agent  which  would  close  the  entrance  to 
the  air-passages. 

In  case  the  asphyxiating  agent  which  has  entered  the  air- 
passages,  be  a  liquid  or  a  semi-liquid  material,  then  tracheotomy 
is  urgently  demanded  as  an  aid  in  restoration;  since  it  opens  a 
more  direct  way  by  which  the  material  may  be  removed.     Tiiis 


tracheotomy;  bkoxchotomv.  lOUy 

subject  lias  been  studied  by  Sclililler,  of  Greifswald.  After  the 
entrance  of  such  matter,  he  finds  that  it  is  in  vain  to  attempt 
removal  by  emetics,  since  the  patient  is  so  nearly  dead  that  these 
cannot  act;  it  is  better  to  make  a  tracheal  opening  as  Hueter  has 
practiced,  and  through  this  pass  a  flexible  tube,  and  by  suction 
extract  the  matter. 

Schiiller  experimented  on  animals  to  determine  to  what 
extent  the  presence  in  the  air-passages  of  such  materials  can  be 
tolerated.  He  found  tliat  if  water  were  slowly  admitted  along- 
with  air,  a  large  quantity  could  be  borne  with  impunity;  in 
twenty -five  minutes,  there  was  admitted  an  amount  of  water 
equal  to  one-thirtieth  of  the  rabbit's  body.  The  animal  lived  for 
some  da^'s,  after  such  addition  of  water  to  the  blood.  An  exam- 
ination of  the  lungs  did  not  reveal  any  special  changes  in  their 
tissue;  the  water  had  disappeared  through  absorption.  The 
animals  thus  treated,  as  a  rule,  lived  but  a  few  daj^s  ;  proving 
that  the  sudden  introduction  into  the  blood  of  such  large  quan- 
tities of  water  imperils  or  destroys  life.  Milk  was  also  injected, 
and  considerable  quantities  of  it  were  tolerated ;  and,  on  necropsy, 
it  was  found  that  the  most  of  it  had  been  absorbed;  3'et  milk 
globules  were  found  in  the  interstitial  tissue  of  the  lungs.  The 
lungs  were  found  to  possess  the  power  of  absorbing  a  considera- 
ble quantity  of  milk ;  but  if  a  thicker  or  semi-liquid  material 
was  thrown  in,  but  a  small  quantity  of  it  was  tolerated.  Thus  of 
a  mixture  of  milk  and  flour,  or  of  flour  and  water,  not  more  than 
three  cubic  centimetres  could  be  tolerated,  while  of  pure  water 
thirty-two  cubic  centimetres  could  be  borne.  After  the  injection 
of  the  mixture  of  flour  in  limited  amount,  the  animal  continued 
to  live;  and  afterwards  wdien  killed,  remains  of  tlie  flour  were 
found  in  the  alveolar  tissue  of  the  lungs. 

Schiiller  concludes  that  simple  artificial  respiration  does  not 
aid  in  restoring  the  patient  sufl'ocated  by  semi-fluid  material;  in 
fact,  it  tends  to  imbed  such  matter  more  deeply  in  the  branches 
of  the  bronchi;  but  more  effectual  aid  will  be  rendered  the  sub- 
ject of  such  asphyxiation,  if  a  tracheal  opening  be  made,  and 
through  this  a  tube  be  introduced  and  the  material  directly 
drawn  out  through  suction  through  the  tube.  But  if  the  material 
be  a  thin  liquid,  then  artificial  respiration,  unaided  by  such 
aspiration,  will  suffice  to  cause  the  expulsion  of  the  matter. 

Schiiller  discovered  that  the  amount  of  the  liquid  or  semi- 
liquid  material  which  could  be  introduced  varied  according  to 
the  kind  of  animal  experimented  on;    thus  the  rabbit  was  less 


1010  I'lIARVXGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

tolerant  tliaii  the  doo- ;  the  do<i  would  bear  the  introduction  of  a 
quantity  of  water  equal  to  one-fourth  the  weight  of  his  body. 
Also,  the  manner  in  which  the  material  was  introduced  had  an 
inlluence  on  the  amount  which  could  be  borne:  thus,  if  slowly 
introduced,  a  much  greater  amount  was  borne  than  if  it  were 
injected  rapidly. 

Along  with  this  worlc  of  as{)iration  that  of  artificial  respiration 
should  be  done;  and  this  may  bo  done  synchronously  through 
traction  on  the  limbs;  or  it  may  be  done  alternately  with  aspira- 
tion done  through  the  tracheal  0})cning. 

In  all  these  ca.ses  of  restoration  from  apparent  deatli,  in  which 
traciieotomy  is  done,  it  will  not  be  necessary  to  retain  the  tube  in 
place  for  a  long  time;  for  as  soon  as  restoration  has  been  fully 
accomplished,  the  canula  can  be  removed,  and  the  wound  closed. 

An  important  indication  for  tracheotomy  is  constriction  of  the 
tracheal  or  laryngeal  canal  through  some  disease  seated  in  the 
walls  of  these  passages;  and  such  disease  is  oftenest  tubercular  or 
syphilitic:  more  frequently,  syphilitic.  This  has  been  studied  by 
Tre'lat,  who,  in  18G0,  wrote  on  the  subject  from  the  observation 
of  two  cases,  and  from  the  liistory  of  twenty-five  others  found  in 
surgical  literature. 

Trelat  finds  that  the  ravages  of  syphilis  in  the  air-passages 
diminish  as  one  descends  towards  the  lungs.  The  morbid 
changes  occur  oftenest  in  the  larynx;  and  the  points  usually 
ulcerated  are  the  aryteno-epiglottidean  folds,  and  the  base  of  the 
epiglottis.  In  only  five  cases  was  the  ulceration  found  in  the 
trachea.  Stenosis  from  such  lesion  occurs  only  in  the  later 
stages  of  the  disease.  The  primary  gummy  infiltration  continues 
for  a  longer  or  shorter  time;  then  ulceration  succeeds;  and  finally, 
this  cicatrizes,  and  narrows  the  passage.  Some  four  or  five  years 
are  required  to  reach  this  contractile  period.  As  verifying  this, 
in  seventeen  cases  tracheotomy  was  done  only  after  five  years 
and  a  half  had  elapsed  from  the  beginning  of  the  sy})hilitic 
disease.     Of  these  seventeen  cases  four  died. 

Demar(|uay  made  a  study  of  this  subject,  and  found  that 
syphilitic  ulceration  in  the  adult  often  leads  to  stricture.  Symp- 
toms of  such  narrowing  are  impeded  respiration  without  loss  of 
voice  the  breathing  is  labored,  and,  in  in.spiration,  the  larynx  is 
drawn  down  towards  the  sternum.  There  is  immobility  of  the 
larynx  and  trachea  during  swallowing;  and,  finally,  the  trachea 
and  the  tissues  about  it  seem  thickened.  When  such  symptoms 
ai)pear,  Demarquay  performs  tracheotomy. 


tracheotomy;  bronchotomy.  1011 

In  case  the  stricture  lies  deep,  the  tracheal  opening  should 
be  made  just  below  it;  thus,  the  stricture  is  accessible  from 
underneath,  and  in  some  cases,  its  dilatation  has  been  accom- 
plished. For  the  work  of  widening,  special  instruments  in 
graded  dimensions  are  needed.  One  which  Trelat  used  was  a 
canula  consisting  of  four  blades,  so  divided  that  the  blades  could 
be  separated  or  spread  apart;  and  thus  dilatation  could  be  slowly 
or  rapidly  done.  Such  dilatation,  to  be  successful,  must  be 
patiently  continued  many  months. 

It  has  fallen  within  the  experience  of  the  writer  that  there  are 
cases  in  wdiich  the  dilatation  cannot  be  satisfactorily  accomplished; 
and  in  such  the  canula  must  be  continuously  carried.  Tlie 
patient  finally  tolerates  the  instrument,  and  becomes  oblivious  of 
the  annoyance  which  it  gave  in  the  commencement  of  its  use. 
When  the  canula  must  remain  permanently  in  the  trachea,  it 
should  be  provided  with  a  fenestra,  through  which  enough  air 
can  pass  to  awaken  the  vocal  chords  to  vibration;  and,  thus 
provided,  the  patient  can,  at  will,  close  the  outlet  of  the  canula 
with  his  fingers,  and  force  the  expired  air  to  pass  through  the 
glottis,  and  do  the  service  of  phonation.  A  canula  which  must 
remain  long  in  place  is  better  constructed  of  hard  rubber  than  of 
metal:  since  the  latter  corrodes,  or  is  tarnished  by  the  excreta 
which  constantly  come  in  contact  with  it. 

An  occasional  demand  for  the  operation  is  an  aneurism  press- 
ing on  some  portion  of  the  air-canal,  and  which  is  so  located 
that  the  trachea  can  be  opened  below  it.  Such  an  aneurism 
might  arise  from  the  primitive  or  secondary  carotids,  and 
possibl}^  from  a  branch  of  the  subclavian  artery.  This  indica- 
tion, according  to  the  writer's  experience,  is  rare. 

A  body  entering  the  oesophagus,  and  too  large  to  be  swallowed, 
has  pressed  on  the  trachea  and  nearly  closed  it.  In  such  a  case, 
should  the  attempt  to  remove  the  body  fail,  and  suffocation  be 
impending,  or  apparent  death  have  supervened,  then  tracheotomy 
should  be  speedily  done;  and  the  emergency  having  passed,  steps 
may  be  taken  for  removing  the  compressing  object;  and  when 
this  has  been  accomplished,  remove  the  canula  and  close  the 
wound. 

A  neoplasm  may  spring  from  the  inner  wall  of  the  larynx  or 
trachea,  and  interfere  with  respiration;  if  in  the  trachea,  such 
growth  is  most  easily  removed  through  an  opening  made  into 
the  trachea;  and  afterwards,  a  canula  may  be  worn  for  a  short 
time,  or  the  wound  may  be  closed  at  once.     Such  opening  should 


1012  I'lIARYXGEAL    AND    (ESOPHAGEAL    NEOPLASMS. 

be  mtide  at  a  j^oiiit  which  will  render  the  growth  most  accessible. 
Tlie  adept  in  tracheoscopy,  and  who  is  expert  in  the  manipula- 
tion of  instruments  in  the  air-])assages,  miglit  possibly  reach  tlie 
growth  per  iv'rts  nrt?»ra^(?s,  and  extir})ate  it;  yet  such  visual  and 
manual  art  is  too  infrequent  to  render  it  probable  that  the  work 
will  ever  be  withdrawn  from  the  province  of  the  general  surgeon. 
There  is  a  winged  insect  whicli  the  writer  once  heard  Milne- 
Edwards  describe,  which  bores  through  the  base  of  the  corolla  to 
the  treasure  to  which  the  long  tube  denies  access;  in  a  similar 
way,  the  surgeon  niakes  a  short  route  to  the  growth  by  opening 
the  trachea. 

A  uecessity  for  tlie  operation  may  occur  from  the  })alsy  of  the 
inferior  laryngeal  nerve,  whereby  the  posterior  arytenoid  muscles 
lose  their  function  of  maintaining  patency  of  the  glottis.  Such 
indication  is  rare,  since  it  will  rarely  happen  that  the  two  are 
palsied;  unilateral  palsy  would  cau.se  but  partial  closure;  never- 
theless, Ziemssen  has  collected  a  few  cases  of  the  so-named  recur- 
rent palsy,  and' in  six  cases  tracheotomy  was  done  to  save  life. 
Mackenzie  saw  ca.ses  of  palsy  of  the  outer  muscle  of  the  larynx 
which  caused  stenosis  of  the  glottis.  The  posterior  arytenoid 
musclemay  be  temporarily  paralyzed  b}'' hysteria;  in  such  patient 
to  open  the  trachea  would  be  an  error;  electrization  should  be 
resorted  to;  or  the  cold  douche,  if  continued  long  enough,  will 
conquer  the  rebellious  muscles,  Skey  quaintly  remarks. 

Therecurrent  nerve,  on  one  side  curving  around  tlie  aorta,  and 
on  the  other,  around  the  right  subclavian  artery,  may  be  com- 
pressed by  aneurism  at  these  sites;  thus  recurrent  palsy  arising, 
some  relief  of  the  consequent  dyspnoea  has  been  obtained  by 
tracheotomy. 

In  tetanus,  the  dyspnoea  which  arises  from  spasmodic  contrac- 
tion of  the  laryngeal  muscles,  may  have  palliation  through 
tracheotomy.  In  such  a  case  the  author  performed  it,  and 
though  the  patient's  life  w^as  not  saved,  yet  it  was  prolonged,  and 
his  condition  made  more  tolerable. 

Tracheotomy  is  sometimes  done  as  a  prophylactic  preliminary 
against  the  entrance  of  blood  into  the  windpipje,  during  operations 
on  the  tongue,  floor  of  the  mouth,  maxilhe  and  pharynx.  For 
this  purpose  it  was  done  by  Xu.ssbaum  prior  to  1870;  but  in  1S70, 
an  improved  method  of  doing  the  work  was  [)roposed  by  Below 
and  Trendelenberg.  Below's  plan  was  to  open  the  trachea,  and 
pass  in,  and  inflate  an  elastic  balloon  above  the  wound;  thus 
done,  blood    descending   from    the  parts  above  could  not  pass 


tracheotomy;  broxchotomy.  1018 

beyond.  Trendelenberg  made  a  study  of  such  tamponing,  and 
found  that  Below's  plan  was  imperfect;  and  besides,  the  tampon 
caused  constant  irritation  and  cough.  To  shun  tliese  inconven- 
iences Trendelenberg  invented  a  tampon  that  was  similar  to  a 
small  India-rubber  balloon  which  surrounded  the  vertical  stem 
of  the  canula;  and  when  the  latter  was  inserted,  the  balloon  being- 
uplifted,  the  trachea  was  completeh'  occluded,  so  that  nothing 
could  descend  below  the  canula. 

The  writer,  in  cases  in  which  only  temjDorary  tamponing  is 
needed,  has  accomplished  this  work  in  a  somewhat  different 
manner,  as  follows:  an  ordinar}^  canula  is  inserted  in  the 
tracheal  opening,  and  then  the  phar\'nx  Is  closely  plugged  with 
a  sponge;  thus  prepared,  any  cutting  procedure  can  be  done  on 
the  parts  above,  without  risk  of  the  blood  entering  either  the 
oesophagus  or  the  air-canal.  As  soon  as  the  bleeding  has  been 
controlled,  the  sponge  may  be  removed;  and  the  canula  can  be 
left  in  the  trachea  for  whatever  time  the  case  recjuires. 

But  if  the  case  be  one  in  which  the  healing  will  be  tedious, 
and  the  excreted  detritus  may  be  considerable,  to  guard  aigainst 
the  descent  of  the  latter  to  the  lungs,  and  the  resultant  ichorous 
pneumonia,  then  the  canula  with  tampon  should  be  used.  Such 
canulated  tampon  maybe  continued  in  place  for  eight  or  ten 
days;  and  even  if  it  be  continued  for  a  longer  period,  no  ill 
results  from  it.  An  objection  that  can  be  urged  against  this  pro- 
cedure is  that  in  some  cases  the  tampon  causes  an  irritating  cough. 
And  the  same,  however,  might  be  urged  against  the  simple 
canula;  in  his  experience  in  its  use,  the  writer  has  met  with 
patients  in  whom  the  inserted  canula  caused  an  irritating  cough; 
and  it  could  only  be  borne  by  giving  some  medicine  to  lessen 
this  irritability;  and  for  this  purpose,  the  camphorated  tincture 
of  opium  may  be  given  to  a  child,  or  morphia  to  an  adult;  and 
instead  of  these  remedies,  the  bromide  of  potassium  maybe  given 
in  doses  of  three  grains  to  the  child,  and  a  larger  amount  to  an 
adult;  and  such  remedy  need  only  be  continued  until  tolerance 
of  the  canula  has  been  acquired. 

Of  the  various  emergencies  or  morbid  condhions  which 
demanded  tracheotomy,  the  one  which  stands  preeminently  in 
the  foreground,  is  stenosis  of  the  air-canal  caused  by  croupal  or 
diphtheritic  neoplasm.  Whether  this  occluding  neoplasm  is  of 
single  or  dual  origin  is  more  a  matter  of  controversy  among 
pathologists  than  among  practitioners  of  medicine  who  Imve 
frecj^uent  opportunities   to  observe  the  disease.     American  and 


1014  l'IIARY.\(iKAI.    AND    (KSOl'II  A<  iKA  Ti    NKOl  1.  ASNFS. 

English  pliysiciiuis  agree  in  the  nuiiii  that  crouf)  ;iin]  (liphtlioria 
are  difi'ereiit  and  distinguisiiable  diseases;  the  Freiicli,  liei-e,  as  on 
another  great  pathological  question,  are  divided  into  unicists  and 
dualists;  the  Germans,  as  a  rule,  teacli  that  croup  and  diphtheria 
are  different  forms  of  the  same  disease.  The  writer's  observations 
confirm  him  in  accepting  the  doctrine  of  duality,  viz.,  that  there 
are  two  diseases,  in  which  the  inflammatory  process  is  followed 
by  the  appearance  of  a  membranous  structure  on  the  mucous 
surface  of  the  air-passages.  This  pseudo-mombranous  develop- 
ment is  much  more  limited  in  crou])  than  in  diplithei'ia;  in  the 
former,  the  false  membrane  a[)pcars  chiefly  in  the  larynx  and 
trachea;  but  the  diphtheritic  neoplasm,  besides  appearing  in 
these  parts,  is  present  on  the  mucous  membrane  of  the  entire 
pharynx  and  nasal  passages.  The  diphtheritic  growth  has  been 
seen,  as  a  rare  occurrence,  on  the  mucous  lining  of  outlets  of  the 
genito-urinary  organs,  and  the  rectum. 

When  compared  in  respect  to  contagiousness,  croup  is  not 
communicable,  while  diphtheria  is  eminently  so.  Croup  is  the 
disease  of  infants,  and  is  only  exceptionally  seen  in  adults; 
diphtheria  occurs  in  both  infants  and  adults.  Croupal  disease  is 
limited  and  suporticiul  in  site;  diphtheria,  besides  its  tendency 
to  superficial  invasion  and  generalization,  penetrates  inwards; 
and  the  se})tic  principle  existing  in  the  affected  surface  is  conveyed 
by  the  lymphatics  to  the  neighboring  glands,  and  awakens  in  the 
latter  a  rapid  cell-growth.  This  glandular  enlargement  occurs 
first  in  the  floor  of  the  mouth,  and  at  the  angle  of  the  lower  jaw; 
thence  it  extends  downwards  on  the  side  of  the  neck,  in  the 
chain  of  glands,  which  are  adjacent  to  the  large  cervical  vessels. 
This  glandular  enlargement  is  remarkable  for  its  rapid  develop- 
ment, and  the  great  volume  to  which  it  can  attain  in  a  brief 
time.  In  croup,  such  glandular  implication  does  not  occur.  The 
di^jhtheritic  disease  may  aflect  the  sinuses  of  the  dura  mater  and 
cause  coagulation  of  blood;  and  thus  the  encephalic  circulation 
may  be  fatally  interrupted,  as  was  the  case  in  a  patient  of  which 
the  writer  witnessed  the  necropsy  made  by  Bouchut.  Such 
thrombus  or  embolism  in  the  vessels  of  the  cord,  may  account 
for  the  palsy  that  sometimes  follows  diphtheria. 

The  results  of  tracheotomy  differ  greatly  in  the  two  cases:  an 
operation  in  the  patient  of  diffused  false  membrane  rarely  saves 
life;  but  in  the  patient  in  whom  the  disease  is  confined  to  the 
larynx  and  trachea,  life  is  often  saved.  From  these  clinical  facts 
the  inference  is  deducible  that  the  distinction  of  these  morbid 


tracheotomy;  bronchotomy.  1015 

processes  into  two  different  classes  is  not  only  permissible,  but  it 
is  necessary. 

And  filially,  on  the  scene  of  this  investigation,  another  witness 
appears:  the  bacteriologist  finds  a  microphyte  which  is  present  in 
diphtheria,  and  is  absent  in  croup;  and  to  this  microphyte  is 
assigned  the  causal  agency  of  the  diphtheritic  process.  This 
microphyte  may  be  the  inceptive  factor  in  causation;  but  the  sub- 
sequent dissemination  of  the  disease  is  partly  due  to  the  septic 
matter  that  arises  from  the  death  and  putrefaction  of  the  mem- 
branous pseudoplasm. 

Returning  from  pathology  to  the  domain  of.  internal  med- 
icine, what  chiefly  concerns  the  tracheotomist  in  croup  and 
diphtheria  is  the  narrowing  of  the  air-canal  by  a  pseudo- 
membrane,  and  which,  unrelieved,  progresses  until  the  laryngo- 
tracheal canal  is  so  small  that  fatal  asphyxia  ensues.  In  eacli 
disease  the  operation  relieves  temporarily  or  permanently  the 
oppressed  respiration,  and  furnishes  air  by  wdiich  the  circulating 
blood  is  unburdened  of  the  carbonic  acid  which  unfits  it  for  the 
maintenance  of  life. 

For  a  time,  the  anatomists  led  by  Allan  Burns  tauglit  that 
serious  ill  would  result  from  the  vertical  section  of  the  cervical 
fasciae  which  overlie  the  trachea,  and  were  supposed  to  relieve 
the  tube  of  some  of  the  pressure  of  the  atmosphere;  but  the 
operation  repeated  innumerable  times  has  long  since  demonstrated 
the  groundlessness  of  these  apprehensions;  exposure  of  the  canal 
in  the  otherwise  healthy  subject  is  not  followed  by  collapse  of  its 
walls;  and  after  recovery  from  such  exposure  or  section,  the 
trachea  loses  none  of  its  functions. 

The  time  when  the  operation  is  done  in  these  diseases  has 
great  bearing  on  the  successful  or  unsuccessful  result;  an  unsuc- 
cessful result  too  often  depends  on  delay  in  the  work.  When  the 
tissues  are  once  laden  with  non-aerated  blood,  the  free  admission 
of  air  into  the  lungs,  though  it  mitigates  the  urgent  symptoms, 
yet  often  comes  too  late  to  the  rescue.  Hence  the  watchword 
should  be  to  meet  the  enemy  early,  before  he  has  mastery  of  the 
citadel.  The  advance  of  the  disease  is  insidious  and  by  no  means 
uniform ;  the  neoplastic  structure,  in  some  cases,  developing 
slowly,  in  others,  rapidly.  An  enumeration  here  follows  of  the 
symptoms  which  denote  that  the  subject  of  croup  or  diphtheria 
has  reached  the  stage  in  which  delay  is  perilous:  The  inspiratory 
act  is  made  with  effort,  and  it  is  accompanied  by  a  hissing  sound 
from  the  air  being  sucked  through  the  narrowed  canal;  and, 


1016  PHARYNGEAL    AND    CESOPIIAGEAL    NEOPLASM.^. 

at  the  same  time,  from  the  vibration  of  the  vocal  chords,  a  hoarse 
or  croaking  sound  is  produced.  Tliis  sound  may  besimuhited  by 
the  vocal  sound  which  is  made  when  air  is  drawn  into  the  lungs : 
such  phonatioD  as  the  ventriloquist  sometimes  uses  in  his  art. 
From  an  insufficient  quantity  of  air  reaching  the  lungs,  the  blood 
is  iniperfectly  oxygenated;  and,  that  venous  blood  is  circulating 
in  the  arteries  is  apparent  in  the  cyanosed  or  purpli^^h  hue  of 
the  lips  and  cheeks.  And  as  a  result  of  this,  the  })atient  is  in  a 
state  of  partial  anaesthesia,  so  that  an  incision  awakens  but  slight 
pain.  This  anaesthetic  condition  has  been  especially  noticed  by 
Bouchut.  Though  such  insensibility  to  a  wound  exists,  yet  the 
patient  is  in  a  state  of  great  restlessness,  throwing  his  limbs 
hither  and  thither;  and,  in  his  disorderly  movements, the  patient 
seems  seeking  a  position  in  which  he  can  breathe  more  easily. 
In  his  efforts  to  get  more  air,  he  tries  to  catcli  or  seize  it  with  his 
mouth.  And  this  labored  breathing  is  revealed  by  unusual 
movement  of  the  nostrils,  mouth,  neck,  chest  and  prsecordial 
region.  The  nostrils  contract,  the  corners  of  tlie  mouth  are 
drawn  laterally,  and  the  lips,  especiall}^  the  lower  one,  are 
everted.  The  front  })art  of  the  neck,  and  particularly  the  jugular 
fossa,  are  drawn  inwards  and  downwards,  under  the  border  of  the 
sternal  manubrium,  during  the  inspiratory  act;  and  these  parts, 
in  expiration,  recede  again  to  their  normal  position.  The  action 
of  the  diaphragm  is  peculiar:  it  contracts  in  inspiration  as  usual, 
but  as  the  lungs  do  not  receive  enough  air,  through  stenosis  of 
the  afferent  canal,  to  fill  them,  a  vacuum  would  arise  if  the  prse- 
cordial wall  and  the  sides  of  the  thorax  did  not  sink  inwards. 
In  fact,  the  in-sinking  of  the  jugular  fossa  and  the  lower  part  of 
the  thorax  and  prnecordia  is  due  to  the  weight  of  the  external  air 
resisting  the  formation  of  a  vacuum,  which,  otherwise,  would  arise 
within  the  thorax.  Such  change  in  the  form  of  the  chest  occurs 
in  a  far  less  degree  in  the  adult,  whose  costal  structures,  both 
osseous  and  cartilaginous,  are  less  yielding. 

As  the  disease  advances,  the  dysi)noea,  which,  at  first,  was  so 
prominent  a  symptom,  may  lessen  and  awaken  the  illusive  hope 
that  the  disease  is  stayed  in  its  })rogress,  and  that  the  patient  is 
better:  and  thus  the  medical  attendant  may  be  lulled  into  inac- 
tion and  allow  the  precious  moment  to  escape  when  an  operation 
might  have  saved  life.  As  signs  that  the  patient  is  not  better 
are  the  rapid  breathing,  and  the  livid  lip  and  cheek,  showing 
that  venous  blood  is  replacing  arterial;  in  such  cyanosed  patient 
the  insidious  truce  is  an  additional  monitor  to  prompt  surgical 


tracheotomy;  bronchotomy.  1017 

action ;  as  Hippocrates  puts  it,  medicine  failing  to  cure,  the  knife 
may. 

Among  the  advocates  of  tracheotomy  there  are  differences  of 
opinion  in  reference  to  the  site  to  be  cliosen  for  the  work,  the  man- 
ner in  wliich  it  is  to  be  done,  the  risks  whicli  attend  the  operation, 
the  use  or  non-use  of  the  canula,  the  form  of  tlie  latter,  and 
numerous  other  points  of  greater  or  minor  importance;  hence 
with,  perhaps,  some  risk  of  repetition  and  of  tediously  elaborating 
this  chapter,  the  writer  will  proceed  to  the  citation  of  a  number 
of  authorities  who  have  written  on  tracheotome^  and  expressed 
their  opinions  on  these  points. 

Petel,  in  1841,  offered  a  report  of  one  hundred  and  twelve 
tracheotomies,  among  which  were  twenty-eight  cures.  He 
advises  where  the  danger  of  suffocation  is  imminent,  to  make  an 
immediate  incision  into  the  windpipe,  regardless  of  haemorrhage, 
since  bleeding  soon  ceases  after  the  opening  has  been  made.  In 
one  hundred  and  nine  cases  operated  on  by  Trousseau,  in'no  one 
was  he  compelled  to  resort  to  ligature  or  torsion.  After  the  open- 
ing w'as  made,  Petel  used  a  piece  of  sponge,  a  feather,  or  injec- 
tions of  water  to  remove  the  excretions  found  in  the  trachea. 

As  after-treatment  of  the  patients  on  whom  he  had  operated. 
Trousseau,  in  1842,  recommended,  as  an  application  to  the  interior 
of  the  trachea,  a  solution  of  nitrate  of  silver,  in  the  strength  of  one 
grain  to  the  ounce  of  water;  of  this  he  dropped  into  the  canal 
from  fifteen  to  twenty  drops,  four  times  on  the  first  day,  three 
times  the  second  day,  and  twice  the  third  day.  Where  the  cough 
is  dry  and  the  expectoration  slight,  Trousseau  counsels  to  drop 
into  the  trachea,  every  hour  or  two,  from  ten  to  fifteen  drops  of 
water.  A  dry  adhesive  excretion  resembling  mucilage  of  gum 
Arabic,  is  an  ill  omen.  Of  one  hundred  and  twelve  operations, 
twenty-seven  recovered. 

Though  Trousseau  had  no  trouble  from  hsemorrhage  in  his 
operations,  yet  others  have  had ;  and  this  sometimes  depends  on 
vascular  anomaly,  especially  that  in  which  there  is  a  fifth  thyroid 
artery.  Gruber  having  frequently  met  this  artery,  published,  in 
1844,  a  carefully  written  dissertation  on  the  subject.  He  found 
that  it  occurs  one  time  in  ten  cases.  The  vessel  arises  oftenest 
from  the  innominate  artery;  though  sometimes,  it  arises  from  the 
arch  of  the  aorta  between  the  innominate  and  the  left  carotid ;  and 
exceptionally,  it  arises  from  the  carotid  or  the  inferior  thyroid. 
When  found,  it  is  oftener  on  the  right  side.  The  middle  lobe  of 
the  thyroid  gland  was  found  in  one-half  of  the  cases. 
65 


1018  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

Gruber  advises  when  the  opening  is  made  through  the  crico- 
thyroidean  membrane  to  make  the  cut  a  transverse  one,  and 
through  the  upper  third  of  the  space;  that  is,  close  to  tlie  lower 
margin  of  the  thyroid  cartilage. 

In  1850,  Sestier  wrote  exhaustively  on  tracheotomy;  and 
especially  in  its  use  as  relief  in  oedema  glottidis.  As  ill  events, 
which  may  complicate  the  ojx'ration,  are  the  entrance  of  air  into 
the  veins,  and  tlie  entrance  of  blood  into  the  air-passages;  also, 
the  trachea  may  be  imperfectly  opened,  and  it  may  afterwards  be 
occluded  through  swelling  of  the  submucous  tissue.  As  more 
remote  complications  are  suffocation  from  spasm  of  the  bronchial 
muscles,  closure  of  the  bronchi  with  mucus,  bronchitis,  delirium, 
convulsions,  ill  results  from  the  premature  removal  of  the  canula, 
the  entrance  of  fluids  into  the  wound  from  careless  drinking; 
finally,  a  fistula  may  remain  after  the  operation. 

Impending  suffocation  from  oedema  is  an  indication  for  its  per- 
formance. And  if  the  patient  is  dying,  or  has  ceased  to  breatiie, 
Sestier  would  do  it;  and  he  would  u.se  for  opening  the  windpipe, 
the  first  instrument  at  hand;  even  a  ])ocket-knife  would  do,  and 
crooked  pins  might  do  the  service  of  retractors,  and  a  quill  act  as 
a  temporary  canula;  and  in  such  emergency,  he  would  operate 
high  up,  viz.,  througli  the  crico-thyroidean  space,  the  cricoid  carti- 
lage, or  through  the  cricoid  cartilage  and  theupper  tracheal  rings. 
When  a  choice  of  site  is  permitted,  Sestier  would  select  cricotomy 
or  crico-tracheotomy,  since  these  sites  allow  the  best  inspection  of 
the  air-passage:  and  should  the  cricoid  cartilage  be  ossified,  then 
the  section  should  be  made  through  the  upper  tracheal  rings. 
The  Pomum  Adami  serves  as  a  guide  for  finding  the  cricoid. 

For  the  admission  of  air,  a  double  canula  is  a  better  means 
than  the  various  dilators,  which  have  been  employed  for  the 
purpose.  Remove  the  canula  as  early  as  the  condition  of  the 
patient  will  permit:  and  as  the  tracheotomies  described  by  Ses- 
tier were  done  for  the  relief  of  oedema  of  the  glottis,  it  was  gen- 
erally possible  to  remove  the  canula,  at  an  early  period. 

In  1841,  Maslieurat-Lagdraard  wrote  on  the  substitutes 
which  may  be  used  in  place  of  the  canula;  being  led  to  a  study 
of  the  matter  by  an  operation,  in  which  having  no  canula  at 
hand,  he  retained  the  opening  patent  by  means  of  pins  which 
were  bent  into  the  form  of  fish-hooks.  These  bent  pins  after 
being  inserted  into  the  lips  of  the  wound,  and  through  the  subja- 
cent cricoid  cartilage,  were  held  in  place  by  threads  attached  to 
them   and   tied    behind    the   neck.     Instructed    by   the  results 


tracheotomy;  broxchotomy.  1019 

obtained  by  this  plan,  he  afterwards  had  a  dilator  constructed, 
which,  similar  to  eyelid  retractors,  held  the  lips  of  the  wound 
asunder.  The  special  advantage  claimed  for  this  plan  was  that 
the  child,  after  the  o|)eration,  could  lie  on  its  side  and  expecto- 
rate the  matter  from  the  windpipe,  and  thus  dispense  with  the 
frequent  cleansing  which  must  be  done  when  the  canula  is 
employed.  This  method  is  of  special  service  when  the  tracheot- 
om}"  is  done  for  the  removal  of  a  body  that  has  entered  the  air- 
passage,  and  which  not  being  found,  the  wound  must  be  main- 
tained opened  for  the  subsequent  expulsion  of  the  body. 

Des  Chenais  suggests  as  an  improvement  on  Maslieurat- 
Lagemard's  pins  or  wire  spring,  the  use  of  hairpins,  or  iron  wire 
bent  into  proper  form,  and  retained  in  place  by  India  rubber 
bands.  Such  a  device  as  is  liere  proposed  was  constructed  and 
used  by  Dr.  Asa  Clark,  of  Stockton,  California;  having  no  canula 
in  a  case  of  emergency  in  which  he  opened  the  trachea,  he  so 
bent  a  hair-pin  that  when  introduced,  it  retained  the  passage 
open.  And  on  an  occasion  in  which  the  author  found  himself  in 
a  similar  strait,  he  inserted  into  the  wound  a  pair  of  dressing- 
forceps,  of  which  the  handles  were  separated  and  kept  apart  by 
means  of  a  cork,  of  which  the  opposite  sides  were  so  furrowed  that 
the  cork  remained  in  place. 

In  1852,  Thompson  announced  a  mode  of  tracheotoni}'  simi- 
lar to  that  done  by  the  ancients;  to  wit,  he  made  a  transverse 
incision  between  the  first  and  second  tracheal  rings.  He  oper- 
ated with  a  species  of  bronchotome,  of  which  the  blades,  after  the 
opening  was  made,  could  be  separated,  and  a  canula  introduced 
between  them. 

Near  the  same  time,  Chassaignac  announced,  as  an  aid  in 
operating,  a  peculiar  tenaculum  that  was  grooved  on  the  posterior 
side;  when  the  point  of  this  was  fixed  in  the  trachea,  the  scalpel 
was  carried  along  this  groove,  and  an  opening  made,  at  once,  into 
the  trachea;  and  as  soon  as  this  was  done,  a  dilator  was  inserted 
and  the  wound  so  widened  that  a  canula  could  be  introduced. 
By  this  method  Chassaignac  claims  that  the  opening  can  be 
made,  and  the  canula  introduced  so  quickly,  that  no  blood  enters 
the  air-passage. 

Guersant,  in  1851,  reported  one  hundred  and  seventy-one 
tracheotomies,  with  thirty-six  recoveries ;  and,  in  the  work,  he 
says  that  the  special  dangers  to  be  avoided  are  the  vessels  which 
lie  on  each  side  of  the  trachea,  and,  in  the  lower  part  of  the  field, 
the  innominate  artery;  and,  as  a  guard  while  incising,  the  finger 


1020      I'HAKYXGEAL  AND  (ESOPHAGEAL  NEOl'LA.SMS. 

should  be  placed  over  tlie  latter  vessel.  Instead  of  using  a  tenac- 
ulum, Guersant  used  his  finger  to  fix  the  trachea,  and  directed 
the  point  of  the  bistoury  with  the  nail.  He  extracted  the  false 
membranes  with  a  long  pair  of  forceps. 

Pitha,  writing  in  1857,  does  not  find  the  operation  an  easy 
one:  the  position  of  the  trachea  may  be  deep  and  difficult 
of  approacli :  its  calibre  is  sometimes  small ;  it  is  in  constant 
motion;  and  besides  these  obstacles,  the  anxiety  and  unrest  of 
the  patient,  and  the  haste  which  the  surgeon  must  make  to  out- 
speed  death,  are  conditions  of  gravest  moment  which  surround 
this  operation. 

Pitha's  three  sites  for  the  opening  are,  first,  between  the  thyroid 
and  cricoid  cartilages,  second,  above,  and  third  below  the  thy- 
roid isthmus.  The  first  site  is  ill  suited  to  cases  in  which  the 
canula  must  lie  long  in  the  canal,  since  it  can  cause  necrosis  of 
the  adjacent  cartilages.  To  make  this  opening  in  the  adult, 
measure  one  inch  downwards  from  the  hyoid  bone,  and  from  the 
inferior  end,  cut  one  inch  downwards  in  the  median  line.  Having 
found  the  crico-thyroidean  membrane,  cut  transversely  through 
the  upper  third  of  the  space:  thus  incising,  one  .shuns  the 
crico-thyroid  artery,  w^hich  lies  near  the  inferior  edge  of  this 
space.  Be  sure  that  the  cut  has  reached  through  the  mucous 
membrane.  The  bleeding  is  not  great;  and  in  place  of  aspirating 
the  blood  which  enters  the  trachea,  insert  the  canula  as  soon  as 
possible. 

Should  there  be  a  largely  developed  middle  lobe  of  the 
thyroid  gland,  Pitha  operates  below^  it,  unless  it  be  possible  to 
uplift  the  part  and  operate  behind  it:  and  for  such  work,  a  cut 
should  be  made  an  inch  and  a  half  long,  commencing  at  the 
lower  edge  of  the  cricoid  cartilage.  In  the  adult,  an  opening  a 
half  inch  in  diameter,  can  be  made  through  the  crico-thyroidean 
membrane. 

Pitha  praises  the  bronchotome  of  Bromfield,  especially  in  the 
inferior  operation ;  and  here  the  tracheal  rings  should  be  well 
exposed  to  sight,  before  the  instrument  is  used. 

Pitha  objects  to  the  usual  canula,  finding  it  too  short;  also, 
that  its  ill  curved  form  causes  too  much  pressure  on  the  posterior 
wall  of  the  trachea;  and,  as  an  improvement,  he  devised  one  with 
a  catheter-like  beak,  and  which  had  two  oval  fenestrae.  Other 
surgeons  who  used  this  canula  were  not  pleased  with  it,  finding 
that,  by  its  length,  it  irritated  the  trachea;  and  also,  that  the  lat- 
eral fenestra?  easilv  became  obstructed  with  nmcus. 


TRACHEOTOMY;  BRONCHOTOMY.  1021 

About  this  time,  the  observation  was  made  that  pneumonia 
often  followed  tracheotomy.  Pitha  claimed  that  the  pneumonia 
had  already  commenced  when  the  operation  was  done ;  but  Schuh 
finds  the  causal  agency  in  the  operation.  He  contends  that  the 
normal  air-passage  is  shortened  and  made  'rregular  by  the  canula; 
and  also,  that  the  changing  calibre  and  frequent  movements  of 
the  canula,  and  the  occasional  closure  of  it  in  the  work  of  remov- 
ing the  mucus  which  accumulates  in  the  canula  and  trachea,  have 
an  ill  effect  on  the  tender  tissue  of  the  lungs. 

The  large  calibre  of  the  canula  is  sometimes  found  inconven- 
ient by  the  adult  patient;  and  he  breathes  more  easily  when  the 
outer  mouth  is  lessened  by  a  slip  of  adhesive  plaster. 

In  1857,  Fuller  introduced  a  modification  of  the  canula,  which 
consisted  of  an  outer  portion  that  was  composed  of  two  blades, 
speculum-like,  which  could  be  introduced  through  a  small  fissure 
and  dilated;  and  between  the  expanded  blades  the  inner  tube  is 
then  inserted. 

In  1858,  Neudorfer  constructed  a  canula,  which  was  double, 
and  so  arranged  that-  the  outer  tube  could  be  removed.  The 
canula  had  a  small  mirror  attached  to  the  outer  part,  so  that  a 
view  could  be  had  of  the  vocal  chords,  and  of  the  different  jjor- 
tions  of  the  trachea. 

In  1858,  Hard}^  wrote  a  history  of  tracheotomy  from  the  time 
of  Asclepiades  (who  is  reputed  to  have  done  the  first  operation  at 
Rome),  to  Bretonneau  and  Trousseau,  who  gave  the  operation  a 
permanent  place  in  surgical  work.  He  reviews  the  two  methods 
of  opening  the  trachea,  by  one  sudden  cut,  or  by  slow  dissection; 
the  latter  plan,  pursued  by  Trousseau,  Hardy  prefers,  since 
bleeding  is  thus  more  easily  avoided.  An  objection  to  incision 
suddenly  done  is  that  the  cutaneous  cut  may  not  correspond  to 
the  deeper  one.  Hardy  proposed  to  use  the  cricoid  cartilage  as 
the  guiding  landmark  in  the  work  of  tracheotomy. 

In  the  same  year,  Passavant  advised  to  fix  the  trachea  with  a 
tenaculum,  and,  after  the  opening  is  made,  to  retain  the  tenaculum 
for  a  few  minutes,  transfixing  the  tracheal  wall,  as  aid  in  insert- 
ing the  canula. 

In  the  hospital  for  children  in  Paris,  from  1850  to  1857, 
Guersant  performed  three  hundred  and  ninety  tracheotomies ;  of 
these  eighty-six  recovered.  In  most  cases,  the  operation  was 
done  when  the  child  was  near  death.  Guersant  would  not 
operate  in  diphtlieria;  the  condition,  according  to  him,  for  the 
operation  is  a  gradually  increasing  asphyxia;  and  as  long  as  this 
is  only  intermittent,  he  would  delay. 


1022  PHARYXdEAL    AND    ^ESOPHAGEAL    NEOPLASMS. 

In  1859,  Pduli.  of  Laudau,  wrote  a  dissertation  on  tracheotomy, 
in  which  he  formuhited  the  following  doctrines: — 

Tracheotomy,  though  sometimes  necessary  in  croup,  can 
never  become  the  principal  means  of  curing  that  disease.  When 
done  by  an  experienced  surgeon,  the  operation  is  nearly  free 
from  danger;  when  danger  attends  it,  it  is  usually  from  the 
entrance  of  blood  into  the  trachea.  Tracheotomy  should  always 
be  done  before  the  disease  has  gained  mastery  over  the  patient: 
that  is,  before  the  patient  has  lost  his  strength,  and  the  pulse  has 
become  small  and  r/eak;  and  prior  to  the  appearance  of  delirium. 
The  opening  should  be  made  just  below  the  cricoid  cartilage. 

In  185S,  Bouchut  advised  as  a  substitute  for  tracheotomy,  the 
passage  of  a  tube  into  the  trachea  through  the  mouth :  a  method 
that  has  recently  been  revived.  This  procedure  was  examined 
by  Trousseau,  who  reported  adversely  to  it.  In  experiments 
made  on  dogs,  Trousseau  found  that  the  inserted  tube  caused 
ulceration  of  the  glottis;  and  would  probably  end  in  destruction 
of  these  parts.  A  canula  which  has  been  inserted  through  a 
tracheal  incision,  can  be  tolerated  for  a  much  longer  time. 

In  1859,  Fock  reported  twenty-four  cases  of  tracheotomy,  of 
which  twelve  were  successful.  The  children  varied  in  age  from 
fifteen  months  to  nine  years.  The  period  of  recovery  varied 
from  nineteen  to  one  hundred  and  twenty-seven  days,  and  the 
canula  was  carried  from  ten  to  twelve  days,  in  most  cases;  yet  in 
one  it  remained  in  the  trachea  twenty -six  days.  Success  was 
more  often  in  those  cases  in  which,  from  the  commencement  of 
the  disease,  there  was  constantly  augmenting  dyspnoea.  The 
emaciated  child  with  a  long  thin  neck  is  a  better  subject  for 
recovery  than  one  which  has  a  short,  thick  and  adipose  neck 
The  existence  of  the  obstructing  membrane  in  both  the  larynx 
and  the  trachea  does  not  make  the  case  a  worse  one  for  recovery. 
The  work  is  far  from  being  completed  when  the  operation  is  done; 
the  child  must  have  a  skillful  nurse,  who  can  cleanse  the  canula, 
from  time  to  time;  and  the  surgeon  should  see  the  case  twice 
a  day. 

The  advice  in  regard  to  skilled  attention  receives  full  sanc- 
tion from  the  writer  of  this  work ;  more  than  once  he  has  seen 
an  excellent  operation  frustrated  through  the  ignorance  and 
incompetence  of  those  to  whom  the  subsequent  care  of  the 
patient  was  intrusted. 

In  1860,  Barthez  wrote  upon  croup,  and  the  proper  stage  of 
the  disease  for  the  performance  of  tracheotom}'.     He  makes  three 


tracheotomy;  bronchotomy.  1023 

stages  of  the  disease;  in  the  first  there  is  no  dyspnoea;  in  the 
second  stage  it  appears  intermediately;  and  in  tlie  third  one  the 
dyspnoea  is  constant,  and  suffocation  seems  impending;  and 
finally  death  comes  from  asphyxia.  He  finds  but  little  difference 
between  croup  and  diphtheria  ;  there  is  a  toxic  element,  also  one 
of  asphyxia,  in  the  disease,  and  these  elements  are  difficult  to 
distinguish.  Barthez  finds  that  in  the  first  and  second  stages  of 
croup,  relief  may  be  obtained  from  internal  remedies,  but  in  the 
third  stage  the  only  relief  is  from  tracheotomy.  When  the 
disease  is  of  the  pronounced  diphtheritic  form,  there  is  no  relief 
from  either  medicine  or  an  operation;  of  seventeen  operations 
done  in  such  patients,  seventeen  died.  The  appropriate  time  for 
the  operation  is  in  the  second  stage;  done  then,  the  patient  often 
rallies.  If  the  tracheotomy  be  deferred  until  the  third  stage,  the 
child  makes  no  effort  to  expel  the  false  membrane,  or  the  fluids 
which  flow  down  into  the  bronchial  tubes.  But  if  the  opening- 
be  made  earlier,  then  the  admission  of  increased  quantities  of  air 
gives  strength ;  the  child  coughs  vigorously,  and  expels  the  false 
membranes. 

In  1862  an  elaborate  report  was  made  by  Lissard  of  tracheot- 
omies done  by  Roser,  of  Marburg.  Roser  does  the  work  by  slow 
dissection,  and  then  he  opens  just  below  the  cricoid  cartilage, 
dividing  three  or  four  tracheal  rings.  To  separate  and  retain 
asunder  the  lips  of  the  wound,  he  employed  hooked  retractors; 
and  this  device  is  praised,  as  it  enables  the  surgeon  to  operate 
almost  without  an  assistant.  An  elastic  catheter  with  large 
fenestrEe  was  inserted  into  the  opened  trachea,  and  by  means  of 
it,  the  mucus  and  false  membrane  were  aspirated.  And  if  the 
patient  be  asphyxiated,  this  tube  may  be  used  for  blowing  air 
into  tlie  lungs. 

Instead  of  the  ordinary  double  canula,  Roser  used  a  triple 
one,  of  which  each  tube  contained  one  that  was  smaller  than  the 
one  containing  it.  The  external  plate  was  immovable,  and  the 
entering  end  was  conical.  After  the  fourth  or  fifth  day,  when  the 
false  membrane  had  been  entirely  discharged,  then  the  triple 
tube  was  removed  and  replaced  by  one  that  avoided  the  erosion 
caused  by  the  ordinary  tube. 

The  position  of  the  patient  for  the  operation  according  to 
Roser,  should  be  the  recumbent  one,  with  a  support  under  the 
neck,  so  as  to  uplift  the  part  to  be  operated  on.  Sponges  large 
and  small  should  be  at  hand  ;  and  it  is  better  to  clean  these  with 
a  towel  than  with  water.     A  cut  is  to  be  made  reaching  almost 


1024  rilAKYNGEAI.    AND    (ESOPHAGEAL    NEOPLASMS. 

from  the  larynx  to  the  sternum  ;  the  structures  are  to  be  uplifted 
with  toothed  forceps;  thus  small  ])ortions  of  tissue  can  be  uplifted 
and  divided  without  severing  the  vessels.  Anomalous  vessels 
should  be  remembered  and  sought  for  with  the  finger.  The  work 
is  most  safely  done  by  circumscribing  the  vessel  with  a  ligature. 

If  the  thyroid  gland  be  large,  it  can  be  pulled  aside,  some- 
times; in  others,  it  can  be  circumscribed  with  ligature  at  two 
points,  and  divided  between  the  ligatures. 

To  open  below  the  gland  is  difficult  in  children  having  short, 
thick  necks;  for  in  such,  emphysema  often  arises  during  the 
work;  and  a  still  greater  peril  is  that  from  wounding  the  fascia; 
since  from  subsequent  suppuration,  pus  may  pass  behind  the 
sternum. 

Before  opening  the  trachea,  the  bottom  of  the  wound  should 
be  well  explored,  and  the  tracheal  rings  brought  fully  into  view; 
and  when  this  is  done,  the  trachea  should  be  seized  with  toothed 
forceps,  and  being  steadily  held,  an  opening  should  be  made 
leisurely  into  the  canaL  After  the  cut  is  made,  before  inserting 
the  canula,  Roser  passes  a  ligature  through  the  lips  of  the  wound 
on  each  si<lo,  and  ties  these  threads  around  the  neck.  With 
these  ligatures  the  wound  is  under  control,  and  can  be  kept 
patent  during  the  introduction  of  the  canula.  After  cleansing 
the  wound  insert  the  canula. 

After  the  operation  is  completed,  the  child  should  be  placed 
in  a  room  of  which  the  temperature  is  sixty-eight  degrees 
Fahrenheit.  In  many  of  the  cases  oi)erated  on  by  Koser,  this 
precaution  was  neglected;  the  child  was  transported  to  its  home 
through  inclement  winter,  and  no  ill  resulted.  After  the  oper- 
ation, the  child  received  medical  treatment;  it  was  given  calo- 
mel and  bicarbonate  of  soda. 

During  the  after-treatment,  the  child  sometimes  has  trouble 
in  swallowing;  a  convulsive  movement  ensues  that  causes 
strangling.  The  canula  must  be  carefully  watched,  and  cleansed 
from  time  to  time,  with  a  feather. 

An  erosion  or  ulceration  of  the  anterior  wall  of  the  trachea 
may  arise,  and  death  has  arisen  from  this  cause.  If  such  event 
occurs,  try  a  canula  of  different  form.  During  the  subsequent 
treatment  for  the  removal  of  the  excreta  from  the  trachea,  Roser 
sometimes  used  a  catheter.  Should  the  wound  become  covered 
with  diphtheritic-membrane,  touch  the  affected  part  with  nitrate 
of  silver,  or  with  sugar  of  lead. 

Of  forty-two  cases  operated  on  by  Roser,  nineteen  recovered  : 
proof  of  the  excellence  of  his  method. 


tracheotomy;  bronchotomy.  1025 

In  consequence  of  the  perils  attending  tlie  ordinary  method 
of  tracheotomy,  in  1861,  Maisonneuve  advised  a  new  procedure, 
viz.,  incision  from  within  outwards.  The  point  selected  for  the 
operation  was  the  crico-thyroidean  membrane,  and  thence  down- 
wards towards  the  sternum.  He  invented  a  tracheotome  for  the 
work.  The  instrument  is  first  forced  through  the  membrane, 
and  is  then  made  to  cut  the  cricoid  cartilage,  and  the  subjacent 
tracheal  rings.  The  crico-thyroidean  membrane  is  chosen  as  the 
initial  point,  since  it  is  easily  found.  After  the  opening  cut  is 
made,  the  wound  is  enlarged  by  means  of  a  dilating  instrument. 
During  the  cutting,  the  parts  adjacent  to  the  instrument  are  to 
be  pressed  against  the  latter,  so  that  no  blood  can  enter  the 
wound. 

From  observation  of  the  ulcerative  action  which  arises  from 
the  pressure  of  the  canula,  in  1862,  Bouvier  was  led  to  make  an 
exhaustive  study  of  this  instrument.  He  refers  to  Roger,  who 
had  noticed  such  trouble,  and  proposed  changes  in  the  form  of 
the  canula.  In  the  history  of  the  canula,  Bouvier  finds  that 
Fabricius  d'Aquapendente  is  accredited  with  having  first  used  this 
instrument,  of  which  there  have  been  two  forms:  a  lateral  one, 
and  a  central  or  tubular  one.  For  about  two  hundred  years,  the 
lateral  one  was  the  only  kind  used;  and  this  was  inserted  into 
and  occu}ned  one  side  of  the  trachea,  and  it  was  only  in  con- 
tact with  one  side  of  the  air-passage.  It  was  straight  or  curved 
in  form,  and  had  the  disadvantage  of  only  having  the  diameter 
of  the  glottis. 

In  1812,  Maunoir  constructed  a  canula  of  lead,  which  more 
nearly  corresponded  with  the  diameter  of  the  trachea;  and  this 
was  still  further  improved  by  Bretonneau,  who  constructed  a 
canula  of  two  tubes:  one  resting  inside  of  the  other;  and  this 
filled  the  trachea. 

Bretonneau  had  a  suggestion  for  his  invention  in  an  instru- 
ment devised  by  Gendrin,  in  1835.  This  consisted  of  two  plates 
attached  to  a  cylinder,  and  so  arranged  that  the  blades  could  be 
made  to  approach  or  separate,  according  as  change  of  adjustment 
was  required.  This  instrument,  though  popular  for  a  time, 
finally  was  superseded  by  a  dilating,  screw-like  apparatus. 
Though  the  use  of  an  internal  tube,  which  can  be  withdrawn  at 
pleasure,  dates  back  to  an  earlier  period,  when  such  a  device  was 
used  by  Martyn,  yet  to  Bretonneau  is  chiefly  due  the  instrument 
in  its  present  state  of  perfection. 

The    curved   double   canula   has   the   disadvantage   that   it 


lOi^G  i'iiAi;YN(ii:Ai,  AM)  (i;soi*iiA(ii;AL   Ni<:orLASMS. 

presses  aguiiist  and  produces  erosion  of  the  wall  of  the  traehea; 
for  the  trachea  is  straight,  while  the  caiiula  is  curved.  This 
erosive  action  is  increased  when  the  canula  moves  up  and  down, 
or  when  the  patient  bends  his  neck.  Mathieu  advises  to  give 
the  canula  a  curve  equal  to  ninetv  degrees;  yet  Bouvier  thinks 
this  would  be  too  great  in  the  child.  The  external  plate,  which 
is  fastened  to  the  canula,  should  be  fixed  to  the  latter  at  an  angle 
of  thirty  degrees,  so  as  to  lessen  pressure.  And  to  lessen  or 
avoid  pressure,  Roger  had  an  instrument  so  made  that  the  plate 
is  movable,  and  permits  the  attached  canula  to  move  in  all 
directions;  and  such  a  canula  follows  or  yields  to  the  motions  of 
the  neck.  Other  modifications  of  the  canula  have  been  devised, 
with  the  design  of  avoiding  pressure  and  erosion;  these  have 
been  but  partially  successful ;  and  hence  the  prevalent  rule,  to 
remove  the  canula  as  early  as  possible. 

Burow,  of  Konigsberg,  in  1862,  reported  eleven  tracheotomies, 
which  were  done  as  follows:  a  cut  was  first  made  through  the 
skin,  and  then  the  dissection  was  continued  with  toothed  forceps, 
with  which  the  tissues  were  pulled  asunder;  thus  vessels  were 
shunned,  and  if  encountered,  where  they  could  not  be  avoided, 
they  were  tied.  When  the  muscles  have  thus  been  separated, 
the  lips  of  the  wound  are  pulled  apart  by  means  of  eyelid 
retractors;  and  when  the  white  trachea  is  found,  open  it  with  a 
falciform  tenotome.  In  some  cases  Burow  used  a  canula;  in 
others  he  used  a  specially-contrived  dilator. 

In  18G3,  Llicke  observed  that  the  innominate  artery  often 
rises  so  high  that  it  is  imperiled  in  tracheotomy.  This  knowl- 
edge was  verified  to  his  dismay  in  one  case  in  \yhich  finding  the 
tracheal  opening  too  small,  he  continued  the  incision  through 
another  tracheal  ring,  when  a  vessel  was  opened  which  flooded 
the  parts  with  blood,  and  caused  death.  At  the  necropsy  it  was 
found  that  the  cut  had  divided  the  second  to  the  seventh  tracheal 
rings,  and  had  opened  the  innominate  artery.  He  infers  that 
the  operation  is  more  perilous  when  the  incision  is  low  in  the 
neck. 

About  the  same  time  Hueter  examined  the  thyroid  gland  in 
young  infants,  and  found  that  tiie  isthmus  is  so  adiierent  to  the 
trachea,  that  if  one  pulls  the  gland  downward,  he  cannot  expose 
more  than  two  tracheal  rings;  hence  he  counsels  crico- 
tracheotomy. 

Millet,  of  Brussels,  finds  the  following  risks  in  tracheotomy: 
bleeding  from  the  wounded  veins  and  arteries;  blood  entering  the 


tracheotomy;  bronchotomy.  1027 

air-passages  from  detachment  of  the  false  membrane  (and  such 
blood  should  be  sucked  out  with  a  suction  syringe);  wounding 
of  the  thyroid  gland  and  the  oesophagus;  and,  as  later  compli- 
cations, pneumonia,  excessive  secretion  from  the  bronchi  and 
entero-colitis. 

In  1864  a  modification  of  the  tracheal  incision  was  recom- 
mended by  Porter,  of  Dublin;  instead  of  the  vertical  cut,  he 
practiced  cutting  out  a  circular  portion  of  the  wall.  The  advan- 
tages claimed  for  this  plan  were  that  the  canula  could  be  inserted 
more  easily,  and  the  false  membranes,  blood,  and  excreta  could 
be  more  readily  extracted.  Also,  the  canula  completely  fills  the 
round  orifice,  and  there  remain  no  angular  openings  above  and 
below  through  which  blood  can  enter  the  trachea,  as  is  the  case 
when  the  straight  incision  is  made.  Such  oval  opening  can  be 
used  in  cases  in  which  the  canula  cannot  be  borne;  also,  when 
the  tracheotomy  is  done  for  the  removal  of  a  foreign  body  from 
the  air-passages.  Porter  does  not  fear  that  such  loss  of  tissue 
will  lead  to  narrowing  of  the  trachea.  He  makes  the  incision  by 
seizing  the  edge  of  the  vertical  cut  with  a  tenaculum,  when  he 
cuts  out  a  semi-circular  section. 

The  writer  would  offer  as  comment  on  this  plan  of  excision, 
that  it  has  not  been  sufficiently  verified  by  experience  to  justify 
its  adoption;  the  slight  power  of  cartilage  to  reproduce  itself 
where  there  has  been  structural  loss,  is  a  serious  objection  to  it. 
The  contractile  scar  tissue  would  end  in  lessening  the  calibre 
of  the  trachea  in  the  adolescent  subject;  and,  hence,  narrowing 
must  finally  appear,  that  would  trammel  the  freedom  of  respira- 
tion, and  lead  to  intermittent  or  permanent  dyspncea. 

In  1866,  Simon  reported  twelve  cases  of  tracheotomy,  with 
five  recoveries.  He  made  the  operation  by  an  incision  through 
the  cricoid  cartilage,  and  one  or  two  tracheal  rings;  by  this  high 
opening,  the  isthmus  of  the  thyroid  gland,  which  lies  high  in 
young  children,  was  shunned  ;  likewise,  the  thyroid  veins  and  the 
innominate  artery  were  avoided.  An  incision  below  the  thyroid 
isthmus  imperils  these  vessels.  Aftef  the  opening  was  made, 
Simon  introduced  a  catheter,  and  sucked  with  his  mouth  the 
blood  and  mucus  from  the  passage;  and  he  counsels  to  do  this 
with  the  mouth,  rather  than  with  a  syringe. 

The  writer  would  pronounce  this  oral  aspiration  an  unjustifiable 
personal  risk  to  the  surgeon;  and  which  would  hardly  be  consistent 
with  the  Homeric  estimate  of  him,  viz.,  that  he  is  worth  a  thou- 
sand men.     Diphtheria  has  been  contracted  by  medical  men  in 


1028  PHAKYls'GEAL    AND    CESOPHAGEAL    NEOPLASMS. 

this  waj;  and  in  several  cases  it  ended  fatally.  The  warrior 
imperils  or  gives  one  life  for  the  multitude;  but  the  physician 
who  would  aspirate  the  toxic  excreta  does  much  more,  since  he 
risks  his  life  for  the  possibility  of  saving  that  of  an  individual. 

Dusch,  in  1867^  made  a  study  of  the  em])hysematous  infiUra- 
tion  of  air  that  sometimes  occurs  during  the  operation  of  trache- 
otomy; he  attributes  it  to  opening  the  deeper  fascia  near  the 
sternum,  and  as  a  result,  tlie  air  is  sucked  underneath  this 
during  inspiration,  and  thence  diffused  into  the  tissues.  As  soon 
as  the  trachea  is  opened  so  that  air  can  freely  enter,  the  infiltra- 
tion ceases,  and  the  air  which  is  so  diffused  soon  vanishes. 

The  writer's  observations  in  regard  to  the  appearance  of  air  in 
the  tissues  have  led  him  to  an  opinion  differing  somewliat  from 
that  of  Dusch:  instead  of  arising  from  the  outside  air  during 
inspiration,  he  has  seen  the  emphysema  arise  from  air  within  the 
trachea,  viz.,  that  which  was  escaping  from  tiie  lungs  during 
expiration.  During  the  operation,  the  trachea,  l)esides  being 
occluded  with  false  membrane,  lias  its  caHbre  lessened  by  })ressure 
or  by  displacement;  and  in  this  condition  the  author  has  observed 
that  a  prick  made  with  the  tenaculum  or  scalpel  was  instantly 
followed  by  an  escape  of  air,  which,  being  caught  in  the  wounded 
tissue,  at  once  appears  as  an  emphysematous  diffusion  of  air. 
He  has  also  seen  such  infiltration  in  cases  before  the  operation 
had  commenced;  and  then  the  air  had  escaped  between  the 
tracheal  rings;  and  this  could  only  have  happened  during  the 
expiratory  effort.  Hence,  though  the  writer  would  not  wholly 
deny  that  the  air  may  enter  the  cervical  structures  in  the  manner 
claimed  by  Dusch,  yet  he  is  convinced  that  a  frequent  source  of 
origin  is  from  air  witlun  the  trachea;  and  also  that  if  care  be 
used  by  the  operator  not  to  prematurely  pierce  the  canal,  such 
infiltration  may  be  avoided. 

In  1867,  Gueterbock  reported  on  the  operations  done  in  the 
Bethanien  Hospital,  at  Berlin;  recovery  occurred  in  about  one- 
third  of  the  cases  operated  on.  Of  fourteen  tracheotomies  done 
in  children  over  seven  years  of  age,  only  two  recovered. 

In  the  same  year,  Boeckel  published  reports  of  tracheotomy 
done  by  several  operators:  the  recoveries  were  about  thirty-three 
per  cent.  During  a  period  when  the  disease  is  epidemic,  and 
assumes  a  malignant  form,  almo.st  all  the  cases  die;  and  during 
such  season,  Boeckel  would  not  operate;  or  only  exceptionally. 

In  1867,  Bourdillat,  a  French  surgeon,  advised  to  operate  by 
making  a  single  cut;  he  claims   that   this   is   an   easier  and   a 


tracheotomy;  bronchotomy.  1029 

speedier  plan,  and  is  attended  by  less  bleeding  than  the  usual 
plan  of  slow  dissection. 

The  plan  of  opening  by  one  cut,  is  liable  to  the  grave  objec- 
tion that  the  cut  may  pass  through  the  trachea  and  open  the 
subjacent  oesophagus:  such  mistake  in  a  reported  case,  led  to  the 
death  of  the  child. 

Peter,  a  French  authority,  in  1867,  called  attention  to  the 
difficulty  of  operating  on  small  children  in  whom  the  neck  is  fat 
and  thick;  the  tracheal  canal  is  small,  not  being  more  than  two- 
fifths  of  an  inch  in  diameter  in  a  child  aged  seventeen  months. 
In  such  children  there  is  a  risk  of  mistaking  the  thyroid  cartilage 
for  the  cricoid,  a  mistake  made  by  Peter,  who  divided  the  thyroid 
cartilage.  There  is  also  a  danger  that  the  trachea  will  slip,  and 
the  incision  go  astray.  And  in  thus  wandering  from  its  aim,  the 
knife  may  wound  the  closely  contiguous  carotid  artery.  A  case 
was  reported  to  the  writer  in  which  this  occurred,  and  the  victim 
of  the  error  died  from  haemorrhage,  in  a  few  moments.  In  chil- 
dren of  such  conformation,  the  surgeon  runs  the  risk  of  slightly 
wandering  from  his  intended  course  and  incising  the  side  of  the 
trachea.  In  such  a  case,  the  inserted  canula  would  be  deflected 
to  one  side;  and,  situated  thus  during  the  respiratory  movement, 
the  ill-placed  instrument  would  irritate  the  parts,  as  the  writer's 
experience  has  verified. 

In  cases  in  which  croup  and  pneumonia  coexist,  Grisolle  and 
Nelaton  advise  to  perform  tracheotomy  as  a  means  of  relief 
That  tracheotomy  cannot  cause  inflammation  of  the  lung  is  shown 
by  the  fact  that  pneumonia  does  not  arise  from  the  operation 
which  has  been  performed  for  the  removal  of  foreign  bodies  from 
the  windpipe. 

In  1868,  Barthez  made  a  comparison  of  cases  of  croup  in 
which  tracheotomy  was  performed,  with  those  in  which  no  opera- 
tion was  done;  of  the  unoperated  cases,  only  one  in  eleven  recov- 
ered; while  of  those  operated  on,  two  in  seven  cases  w^ere  rescued: 
and  the  operation  should  be  done  early.  He  thinks  that  there  is  a 
fair  future  for  tracheotomy ;  and  that  it  will  not  share  the  fate  of 
trephining,  which  is  falling  into  discredit. 

In  the  same  year,  Steiner  published  the  report  of  fifty-two 
cases  of  tracheotomy,  of  whom  eighteen  recovered.  One  child 
died  from  bleeding  caused  by  the  operation.  From  a  study 
of  the  fatal  cases  in  which  necropsy  was  made,  Steiner  refers 
death  to  one  of  the  following  causes:  a  chronic  swelling  of  the 
laryngeal  mucous  membrane,  which  was  a  sequel  of  the  antece- 


1030  PJIAKVNOKAL    AND    (ESC  )1'1IA(  i KAL    NEOPLASMS. 

dent  croiipal  ])rocess;  or  from  ulceration  from  the  same  cause; 
and  a  third  cause  of  death  was  palsy  of  the  glottis.  Steiner 
operates  as  soon  as  emetics  fail  to  give  relief. 

TJie  risk  to  which  the  surgeon  is  exposed  in  tlie  treatment  of 
croupal  diphtheria  was  illustrated  in  the  experience  of  KroU,  of 
Baden,  in  18GS :  in  the  treatment  of  a  patient,  the  latter  coughed 
out  excreta  which  came  in  contact  with  the  face,  moutii,  eyes,  and 
nose  of  the  physician.  KroU  soon  afterwards  became  the  subject 
of  a  severe  attack  of  tlie  disease,  which  ahnost  ended  fatally.  He 
concludes  that  the  excreted  matter  of  the  diphtheritic  patient 
can,  through  contact,  cause  the  disease  in  a  healthy  person,  and 
the  time  necessary  for  such  development,  as  shown  by  his  own 
case,  is  given  by  KroU  as  about  six  days. 

In  1868,  Hasse  wrote  on  tracheotomy:  his  observations  were 
made  in  the  operations  done  by  Wilms,  of  Berlin.  To  avoid  the 
risks  whicli  attend  the  removal  of  the  canula,  forceps  were  used 
by  the  aid  of  which  the  lips  of  the  wound  could  be  held  asunder, 
and  air  admitted.  Hasse  thinks  the  form  of  the  canula  should 
be  modified.  Instead  of  having  the  form  of  a  quadrant  or  fourth 
of  a  circle,  he  would  give  it  a  curve  of  about  one-sixth  of  a  cir- 
cle: for  the  latter  form  permits  of  the  matter  being  expelled  more 
easily.  His  canula  is  straight  in  its  lower  third,  and  is  one-sixth 
of  a  circle  in  its  upper  two-thirds. 

As  an  aid  in  the  introduction  of  the  canula,  Couper  first 
passed  in  a  small  rod  of  flexible  gutta  percha,  over  which  the 
canula  was  slipped  and  guided  into  the  trachea. 

Huter,  in  1869^  from  an  extended  experience  in  tracheotomy, 
advises  the  section  through  the  cricoid  cartilage.  The  advantage 
claimed  for  this  point  is  its  superficial  position,  and  its  easy 
fixation  with  the  tenaculum.  He  attaches  much  importance  to 
the  aspiration  of  the  matters  collected  in  the  trachea,  after  the 
opening  has  been  made.  And  this  should  be  repeated  after- 
wards, whenever  the  material  collects  in  the  air-passage.  The 
aspiration  was  done  by  the  aid  of  a  flexible  tube,  which  being 
admitted  through  the  wound  could  be  carried  down  to  any  extent 
desired. 

From  a  comparison  of  cases  thus  treated  with  those  not  as}>i- 
rated,  Hliter  finds  that  more  of  the  former  recover;  also,  that  in 
cases  which  ended  fatally,  life  was  prolonged  in  those  in  which 
aspiration  was  practiced. 

In  1872,  there  was  published  a  report  of  three  hundred  and 
thirty  tracheotomies  done  by  Wilms,  in  Berlin  :  of  these,  one  ban- 


tracheotomy;   broxchotomy.  1031 

dred  and  three  recovered ;  that  is,  a  little  over  one-third  of  the  cases 
operated  on.  The  canula  was  removed  between  the  fifth  and  eighth 
days,  as  a  rule.  If  some  hours  after  the  operation  the  pulse  is 
much  accelerated,  it  indicates  a  fatal  ending;  but  a  low  rate  of 
pulse  and  a  diminution  of  temperature  are  signs  of  a  favorable 
termination.  If  after  the  canula  has  been  introduced,  the  respi- 
ration is  not  improved,  but  the  patient  continues  to  breathe 
rapidly,  the  portent  is  unfavorable. 

In  1872,  Bruns  wrote  on  tracheotomy  done  by  means  of  the 
galvano- cautery.  He  states  that  the  operation  was  thus  done  by 
his  father,  in  1867,  and  in  1869.  There  are  other  claimants  for 
priority  in  this  method ;  and  it  is  probable  that  several  operated 
thus,  near  the  same  time. 

Bruns  says  the  operation  with  the  cautery  is  not  so  free  from 
the  danger  of  bleeding  as  has  been  claimed;  indeed,  in  one  case 
he  was  thus  operating  on,  the  heemorrhage  was  so  excessive  that 
he  was  compelled  to  finish  the  work  with  the  knife;  he  also  finds 
that  the  operation  is  by  no  means  an  easy  one.  From  the  state- 
ment of  Bruns  and  others  concerning  galvano-caustic  tracheotomy, 
and  from  the  writer's  personal  observation  of  this  method  of 
incision,  this  plan  seems  really  deserving  of  so  little  commenda- 
tion, that  were  the  author  concerned  in  the  matter  of  its  priority, 
he  would  cheerfully  resign  his  share  of  the  quest  to  others.  The 
writer  was  a  witness  to  a  number  of  operations  done  in  Paris 
with  the  galvano-caustic  knife,  in  1876;  among  them  was  the 
excision  of  a  cancerous  breast,  and  the  removal  of  a  vesical  cal- 
culus. In  the  removal  of  the  breast  the  entire  cutis  was  sacri- 
ficed, and  the  excision,  commencing  at  the  peripheral  margin  of 
the  part,  proceeded  thence  by  concentric  circles  of  detachment, 
until,  after  great  perseverance,  the  task  was  accomplished;  but  so 
much  time  was  consumed  in  the  work,  that,  when  it  was  com- 
pleted, nearly  every  seat  of  the  room  was  empty,  which,  at  first, 
was  filled  with  those  whom  the  fame  of  the  eminent  surgeon  had 
attracted  to  witness  the  new  method  ;  all  learned  that  the  excis- 
ion done  with  the  galvano-caustic  blade,  so  far  from  being  a 
blood-saving  method,  was  a  blood-wasting  one,  and  the  wound 
made  was  of  such  a  form  that  many  weeks  would  be  required  for 
its  closure.  The  first  cystotomy  thus  performed  illustrated  how 
much,  of  barbaric  rudeness  and  uncouthness  can  be  introduced  in 
and  mar  an  operation  which,  by  centuries  of  revision,  has  been 
brought  to  a  marvelous  stage  of  perfection  when  done  by  a 
cold-bladed  knife  in  an  adroit  hand.     And  a  further  remonstrance 


1032  i'iiakyn(;i:af.  and  a:s<M'HAGEAL  neoplasms. 

against  the  method  was  the  near  approach  of  the  patient  to  death 
through  subsequent  inflammation  of  the  wounded  parts.  And 
tracheotomy  done  by  the  thermal  metliod,  must  leave  similar  ill 
concomitants  and  events,  and  prevent  its  further  continuance. 
The  galvano-cautery  in  traclieotomy,  like  some  other  ])rocedures, 
has  had  its  brief  hour  on  the  surgical  stage,  and  will  only  be 
recalled  to  view  by  the  pen  of  the  historian  of  tracheotomy,  and 
by  him  cited  as  an  example  of  the  irrepressible  spirit  of  innova- 
tion that  has  attended  the  develo})ment  of  every  operation  done 
by  the  surgeon. 

Korte,  a  German  writer,  in  1879,  published  an  article  con- 
cerning the  granular  growths,  cicatricial  narrowing,  and  ulcera- 
tion, which  may  follow  and  seriou.sly complicate  tracheotomy:  he 
saw  this,  especially  where  the  operation  was  done  low  down  in 
the  trachea.  As  treatment  of  such  cases,  curetting  and  cauteri- 
zation may  be  resorted  to;  also,  a  canula  of  a  peculiar  form  lias 
been  employed. 

Petel,  of  Paris,  observed  the  granulative  complication  :  after 
the  wound  had  healed,  the  granulative  tissue  grew  inside  to  such 
an  extent  that  the  trachea  was  nearly  occluded,  and  partial 
asphyxia  occurred. 

Madelung,  about  the  same  period,  pointed  out  (Archiv  fiir 
Klinische  Chirurgie)  certain  difficulties  which  may  arise  in  tra- 
cheotomy from  the  presence  of  accessory  or  anomalous  portions  of 
the  thyroid  gland.  He  classifies  these  anomalies,  according  to 
their  site,  into  superior,  lateral,  anterior  and  posterior  accessory 
portions.  And  in  the  adult,  the  anomalous  part  may  become 
goitrous.  Such  thyroid  structure  might  be  so  situated  as  to 
embarrass  the  work  of  tracheotomy. 

Ipsen,  of  Copenhagen,  in  1881,  reported  the  observations  made 
by  Bloch  in  the  necropsies  made  in  thirty  cases  of  unsuccessful 
tracheotomy.  Sloughing  was  found  in  sixteen  cases,  which  had 
arisen  from  the  pressure  of  the  canula.  The  silver  instrument 
becomes  darkened  in  such  cases,  and  the  detaching  slough  may 
be  followed  by  htemorrhage,  which,  in  some  cases,  may  be  so 
serious  as  to  contribute  to,  or  even  cause  death.  The  detached 
slough  may  be  succeeded  by  a  polypoid  mass  of  granulative  tis- 
sue. To  guard  agiiinst  sloughing,  Ipsen  advises  to  use  a  canula 
composed  of  India  rubber,  rather  than  of  silver. 

Zimmerlin,  in  1882,  wrote  on  the  haemorrhage  that  may  arise 
during  the  operation  of  tracheotomy:  he  describes  two  species, 
extra-tracheal  and  intra-tracheal ;  and  it  may  be  arterial,  venous, 


tracheotomy;  bronohotomy.  1033 

•capillary,  or  parenchymatous.  Arterial  bleeding  may  originate 
from  opening  the  innominate  or  the  thyroid  artery;  and  this 
may  arise  primarily,  from  a  direct  wound  of  the  vessel;  or  it  may 
occur  later  from  sloughing,  through  pressure  of  the  canula ;  and 
lisemorrhage  is  more  apt  to  arise  when  the  tracheal  opening  is 
made  low  down.  Venous  haemorrhage  is  from  the  thyroid  veins. 
The  chief  means  of  control  advised  by  Zimmerlin  is  pressure, 
which  is  to  be  made  around  the  canula.  The  author  would  add, 
that  if  the  bleeding  be  from  a  vessel  of  considerable  size,  no 
other  treatment  offers  certain  security,  except  that  of  finding  the 
bleeding  vessel  and  ligating  it.  And  hsemorrhage  will  generally 
be  avoided  if,  at  the  time  of  the  operation,  care  be  used  to  tie 
vessels  which  are  wounded,  or  which,  being  laid  bare,  may  subse- 
quently open  through  pressure  of  the  canula,  or  through  pseudo- 
membranous invasion  and  disintegration. 

Chaym,  of  Berlin,  in  1883,  wrote  on  tracheotomy  in  children 
"under  two  years  of  age;  in  such  subjects  great  difficulties  are 
encountered,  especially  in  the  first  year,  from  the  thick,  fatty 
couch  of  the  neck,  tlie  large  volume  of  the  thyroid  gland,  and 
from  the  smallness  and  mobility  of  the  trachea.  Of  nine  hun- 
dred and  seventy-seven  infants  operated  on  under  two  years 
of  age,  eighty-five  per  cent  died.  To  obtain  better  results 
Chaym  counsels  to  do  the  operation  before  the  appearance 
of  asphyxia;  and  the  opening  should  be  made  just  below  the 
cricoid  cartilage^  not  including  that  part.  By  observing  these 
precautions,  he  finds  that  twenty-nine  children  under  one  year, 
and  fifty-eight  under  two  years  of  age,  were  oj^erated  on  success- 
fully. Chaym  finds  recorded  two  hundred  and  twenty  children 
under  two  years  of  age,  who  were  saved  by  tracheotomy,  Isam- 
bert,  in  1868,  advised  tracheotomy  in  the  infant. 

Gresswell,  in  1884,  wrote  on  the  trouble  of  breathing  wliich 
may  arise  after  the  removal  of  the  canula;  he  disagrees  with 
those  who  refer  this  trouble  to  the  sinking  of  the  tracheal  wall 
around  the  opening  which  has  been  made  through  it;  his  expla- 
nation is  that  the  child  has  unlearned,  or  forgotten,  to  open  the 
larynx  when  the  respiratory  muscles  act.  To  avoid  such  subse- 
quent trouble,  Gresswell  resorts  to  the  novel  artifice  of  creating 
some  dyspnoea  in  the  child,  before  the  removal  of  the  canula ; 
for  this  purpose,  he  devised  a  canula  which  was  provided  with 
lateral  openings,  which  could  be  closed  or  opened  so  as  to  dimin- 
ish or  augment  the  amount  of  admitted  air;  and  thus  the  child 
was  compelled  to  make  some  effort  in  breathing. 
66 


1034  j'iiaryxui<:al  and  (Icsophagkal  xeoi'lasms. 

Besides  the  difficulty  referred  to,  Kolil  in  1887,  mentions  others 
wljich  may  follow  the  removal  of  the  canula:  these  are  relapsing 
diphtheria;  inflammation  of  the  vocal  chords;  granulative  growths 
iu  the  wound;  curvature  and  other  alterations  of  form  which 
may  arise  in  the  air-passage  as  the  result  of  the  operation ;  relax- 
ation of  the  anterior  wall  of  the  trachea;  tracheal  stenosis  due  to 
external  pressure;  primary  or  secondary  palsy  of  the  laryngeal 
muscles;  paresis  from  non-use  of  the  parts;  spasm  of  the  glottis; 
and  too  long  retention  of  the  canula  in  the  trachea.  From  the 
author's  experience,  nearly  all  of  these  troubles  will  be  avoided, 
if  the  canula  can  be  removed  at  an  early  period. 

In  cases  of  croup  in  which  the  pseudo-membrane  penetrates 
deeply  into  the  air-canal,  tracheotomy  will  furnish  but  slight 
relief,  if  means  be  not  used  to  extract  the  false  membrane.  In 
such  patients  after  the  tracheal  opening  is  made,  Pienazck,  in 
1886,  advised  the  use  of  forceps  of  which  the  blades  are  long  and 
narrow;  and  he  claims  that  with  this  instrument  the  surgeon 
can  penetrate  into,  and  extract  the  pseudoplasm  from,  the  right 
and  left  bronchi.  But  in  case  the  pseudo-membrane  penetrates 
into  the  secondary  trunks  of  the  bronchi,  then  it  cannot  be 
reached  with  forceps ;  and  in  such  patients,  death  is  inevitable, 
according  to  Pienazck.  The  writer  in  cases  in  which  the  mem- 
brane has  reached  this  low  site,  has  found  some  relief  in  the 
inhalation  of  an  atomized  solution  of  chlorate  of  potassa,  or  of 
Aqua  Calcis.  The  atomized  vapor  may  be  conducted  into  the 
mouth  of  the  canula  through  a  funnel,  which  has  been  inserted 
into  it. 

After  this  extensive  review  of  the  teachings  of  authorities 
who  have  written  on  tracheotomy  as  a  means  of  relief  of  the 
patient,  who  is  the  su!)ject  of  obstruction  of  the  air-passage 
through  croupal  or  diphtheritic  pseudoplasm,  the  writer  will 
proceed  to  an  application  of  the  principles  deducible  from  these 
doctrines. 

The  first  and  cardinal  point  in  regard  to  the  operation  is  that 
it  be  done  timely,  opportunely  and  jtrudently;  the  moment  for 
opening  the  air-passage  should  be  so  chosen  that  one  may  apply 
to  it  slightly  paraphrased  the  classic  expression  of  Tacitus:  fclix 
opportunitate  mortis  vitandfe  {fovtnnnte  in  the  oppoiiiuiity  of  escap- 
ing death);  and  the  moment  for  operating  should  be  so  chosen 
that  the  surgeon  can  neither  be  accused  of  undue  haste,  nor  of 
fatal  delay.  Dyspnoea  which  is  continuous  and  constantly 
increasin'g,  denotes  that  the  pseudo-membrane  is  encroaching  on 


tracheotomy:  bronchotomy.  1035 

and  lessening  the  calibre  of  the  air-passage;  this  means  that  the 
amount  of  air  being  admitted  is  insufficient  for  the  maintenance 
of  life ;  and  that  cyanosis  will  soon  be  present,  when  unoxygenated 
blood  occup^dng  the  arteries,  the  chances  for  a  successful  opera- 
tion will  be  slight. 

The  site  at  which  the  air-passage  should  be  opened  has  been 
the  matter  of  varying  opinion,  as  the  reader  has  seen  in  the 
previous  citations  of  authorities  on  that  point.  An  enumeration 
of  these  sites  in  the  order  of  their  succession  from  above  down- 
wards is  as  follows:  the  section  maybe  made  between  the  thyroid 
and  cricoid  cartilage;  through  the  cricoid  cartilage;  tlirough  the 
cricoid  cartilage  and  one  or  two  rings  of  the  trachea;  through 
three  or  four  of  the  uppermost  tracheal  rings;  through  the 
tracheal  rings  which  lie  behind  the  isthmus  of  the  thyroid  gland; 
and  lastly,  through  the  portion  of  the  trachea  that  lies  just  below 
the  thyroid  gland.  As  seen,  the  operator  has  amplitude  of  choice 
in  the  selection  of  site. 

The  first  point  mentioned,  which  lies  between  the  thyroid  and 
cricoid  cartilages,  is  too  small  in  the  child  for  the  operation;  but 
in  the  older  subjects  this  space  occupied  by  the  cricoid  ligament 
is  large  enough  ;  and  this  site  is  sometimes  selected  for  what  may 
be  named  inferior  laryngotomy.  The  section  of  the  cricoid 
cartilage  in  the  child  would  not  give  an  opening  which  would 
admit  a  canula  of  sufficient  calibre  for  normal  breathing;  in  the 
adult  it  might  suffice  ;  yet  if  an  opening  were  desired  at  this 
location,  it  would  be  better  to  incise  the  crico-thyroidean  (conoid) 
ligament,  cutting  transversely,  close  to  the  up|)er  margin  of  the 
cricoid  cartilage;  thus  incising,  one  shuns  the  crico-thyroid  artery, 
which  pierces  the  ligament  above  its  middle,  at  a  point  where 
a  lymphatic  gland  is  often  found. 

Should  an  emergency  arise  in  the  adult  from  diphtheritic 
occlusion,  or  other  cause,  demanding  section  through  the  cricoid 
cartilage,  the  work  should  be  done  as  follows:  to  locate  the  part,, 
let  the  finger  pass  searchingly  from  the  pomum  adami  down- 
wards; the  yielding  interstice  filled  by  the  conoid  ligament  will 
be  found,  and  then  underneath  tliis,  the  cricoid  cartilage  is  sit- 
uated ;  though  less  prominent  than  the  thyroid  cartilage,  yet  the 
cricoid  is  enough  so  to  be  distinguishable  from  it,  and  also  from 
the  subsequent  tracheal  ring.  Since  the  crico-thyroid  muscles, 
which  are  somewhat  concerned  in  vocal  function,  lie  on  the 
sides  of  the  cartilage,  these  structures  must  be  avoided  in  the 
division    of  the  cricoid.      And    no   less  important,  though  less 


1030  niAUYXiJEAL    AND    GSSOPHAGEAL    NEOPLASMS. 

imperiled  than  the  muscle,  is  the  external  branch  of  the  su[)e- 
rior  laryngeal  nerve,  which  passing  under  the  sterno-thyroid 
muscle  reaches  and  penetrates  the  cricoid-thyroid  muscle.  The 
operations  of  Ilueter  have  repeatedly  demonstrated  that  the 
cricoid  cartilage  can  be  divided  without  impairment  of  the  voice; 
yet  to  do  this  the  opening  must  be  made  in  the  anterior  median 
line  of  the  cartilage;  and  the  dissection  which  is  done  to  reach  it 
should  be  neath',  and  not  laceratingly  made:  thus  the  nerve  will 
be  shunned  and  the  muscle  left  intact.  A  vertical  line  dropped 
from  the  notch  in  the  t]i3'-roid  cartilage  above,  to  the  sternal 
incisura  (or  hollow  space  in  the  manubrium  of  the  sternum)  will 
indicate  tlio  site  of  the  median  section  to  be  made;  and  should 
the  division  of  the  skin  and  the  platysma  myoid  muscle  have 
wandered  from  the  surgeon's  aim,  correction  can  be  made  by 
continuing  the  incision  through  the  line  which  separates  the 
sterno-hyoid  muscles.  There  is  a  considerable  interval  between 
these  muscles  above;  but  this  becomes  less  below  where  the  two 
muscles  meet;  and  after  contact  in  the  median  line,  they  diverge 
again  as  they  pass  to  their  respective  points  of  insertion.  With 
these  guides,  the  scalpel  need  not  lose  its  way;  finally,  the  white 
cricoid  structure  being  reached,  the  operator  transfixes  it  with  a 
tenaculum,  and  holds  it  steady  while  he  divides  it. 

Isolated  cricotomy  is  no  longer  resorted  to  as  an  operation 
for  the  relief  of  pseudo-membranous  occlusion  of  the  air-passages; 
but  when  this  cartilage  is  divided,  the  section  is  generally  made 
along  with  two  or  more  of  the  tracheal  rings. 

An  objection  against  cricotomy  in  tlie  adult  is,  that  the  cri- 
coid cartilage  in  the  old  subject  is  ossified ;  this  does  not  obtain 
in  the  child,  in  whom  the  cricoid  ring  is  as  easily  divided  as  the 
succeeding  tracheal  rings.  The  operation  thus  done  is  known  as 
crico-tracheotoni}-;  and  this  has  been  decided  as  the  one  which, 
anatomically,  offers  the  most  advantageous  conditions  when  it 
becomes  necessary  to  open  the  infant's  air-passage.  Among 
these  conditions  may  Ije  ]nentioned  the  thinness  of  tlie  soft  parts 
which  must  be  divided,  their  usual  freedom  from  vessels,  the 
certainty  with  which  the  part  may  be  found,  and  the  facility 
which  an  opening  made  there  offers  for  reaching  the  occluding 
membrane,  whether  tlie  latter  be  seated  in  the  larynx  above,  or 
in  the  trachea  below. 

In  the  median  line  of  the  neck,  in  descending  from  the  hyoid 
bone,  the  air-passage  becomes  buried  deeper  as  one  approaches 
the  sternum;  so  that  the  lower  portion  is  quite  impalpable  in 


tracheotomy;  bronchotomy.  1037 

the  child  of  short,  fat  neck ;  but,  fortunately,  in  the  critical 
moment  which  demands  prompt  and  speedy  action  on  the  part 
of  the  tracheotomist,  there  is  for  him  a  landmark  which  can 
always  be  easily  felt,  though  it  may  not  be  visible:  this  is  the 
prominent  eminence  of  the  thyroid  cartilage:  a  cartilage  which, 
in  the  work  under  consideration,  is  not  to  be  touched  by  the 
scalpel;  but  in  the  infant,  the  finger  passing  directly  downwards 
from  this  point  a  half  inch,  can  fix  the  point  where  the  scaljDel 
being  held  vertically,  is  to  be  thrust  downwards  and  backwards; 
and  this  incision  is  to  be  continued  until  it  encounters  the  white 
cricoid  ring,  below  which  lies  the  trachea,  of  which  one  or  more 
rings  are  to  be  divided. 

Besides  the  thinness  of  the  soft  parts  which  rest  on  the  cri- 
coid cartilage  and  upper  tracheal  rings,  these  structures  are  less 
often  traversed  by  vessels  which  would  bleed  freely,  if  cut, 
than  are  the  structures  lower  down.  A  third  advantageous  con- 
dition which  this  site  offers  is  that  the  air-canal  can  be  found 
more  readily  here,  than  below;  the  finger  can  easily  distinguish 
the  cricoid  ring  by  its  unyielding  firmness;  and  its  separate 
mobility  from  the  thyroid  cartilage  above  will  enable  the  opera- 
tor to  avoid  the  latter.  And,  finally,  an  opening  made  here 
enables  the  surgeon  to  remove  the  false  membrane  which  may 
lie  in  the  passage  above  and  below  the  opening.  The  conditions 
enumerated  speak  strongly  in  favor  of  the  crico-tracheal  site, 
which  Hueter  and  other  authorities  unite  in  selecting  as  the 
appropriate  one  for  the  performance  of  tracheotomy. 

The  next  site,  viz.,  through  the  upper  tracheal  rings,  is  usu- 
ally so  encroached  on  by  the  isthmus  of  the  thyroid  gland  that  it 
offers  insufficient  space  for  the  opening;  in  fact,  the  isthmian 
bridge  commonly  spans  the  passage  at  a  point  corresponding  to 
the  second  tracheal  ring;  and  occasionally  an  anomalous  lobe  so 
encroaches  on  the  limited  space,  that  the  latter  is  quite  too  nar- 
row for  operating  here. 

The  post-isthmian  site  is  rarely  a  suitable  one  for  the  opera- 
tion; the  vessels  in  the  isthmus  are  often  of  such  calibre,  that 
the  section  would  cause  copious  bleeding:  an  event  which  seri- 
ously embarrasses  the  operation;  in  fact,  in  many  cases,  such 
bleeding  has  caused  death.  In  some  cases,  however,  the  isthmus 
is  only  a  thin  filamentous  structure,  in  which  only  diminutive 
vessels  exist;  in  such  favorable  conditions  the  tracheal  section 
could  be  made  at  this  point. 

Below  the  isthmus  of  the  thyroid  gland  there  is  a  space  of  vary- 


1038  PHARYXciKAL    AND    U>OI'IIAUEAJ>    NICOIM.ASMS. 

ing  distance  in  which  tlie  trachea  niay  be  opened;  in  the  child  of 
lone:,  thin  neck,  there  is  ample  room  lor  the  work;  but  in  a  neck 
which  is  short  and  thick,  this  site  is  ill  fitted  for  tracheotomy.  An 
advantage  which  the  opening  here  offers  is  this,  that  section  made 
there  will  probably  be  below  the  diseased  portion  of  the  air- 
passage;  the  pseudo-membrane  will  be  above  the  fenestra  opened 
by  the  surgeon  in  the  tracheal  tube.  Objections  which  some- 
times far  outweigh  this  advantage  are  the  occasional  anomalies 
of  the  vessels  in  this  region,  to  which  some  reference  has  been 
made;  the  innominate  artery  may  rise  unusually  high;  it  was 
once  seen  by  Allan  Burns  so  high  that  it  reached  the  lower, 
border  of  the  thyroid  gland;  he  saw  also  the  right  carotid  cross 
in  front  of  the  trachea.  Both  carotids  may  originate  from  the 
innominate,  and  then  the  left  one  will  cross  the  trachea.  The 
inferior  thyroid  artery  may  arise  anoujalously  as  a  single  trunk 
from  the  sub-clavian;  and  then,  as  stated  by  Burns,  tlie  vessel  is 
so  situated  as  to  be  endangered  in  the  operation.  These  anom- 
alies are  so  frequent  that  the  surgeon  may  expect  to  encounter 
one  of  them  in  eight  cases:  frequency  sufficient  to  command 
cautious  advance  of  the  knife.  Again,  the  gradually  deepening 
position  of  the  trachea,  as  one  approaches  the  sternum,  is  a  disad- 
vantage that  is  present  in  all  patients,  and  is  especially  serious 
in  the  short,  adipose  neck. 

Despite  these  several  impediments,  this  site  was  the  favorite 
of  one  of  the  most  celebrated  surgeons,  B.  von  Langenbeck,  whose 
operations  the  author  has  repeatedly  witnessed.  The  deliberate 
manner  in  which  this  eminent  surgeon  operated  enabled  him  to 
shun  the  perilous  vascular  anomalies  which  occasionally  occur 
there;  and  should  the  right  or  left  carotid  have  encroached  on 
the  trachea,  or  the  subclavian  have  reversed  its  course  and  desti- 
nation, or  any  of  the  vascular  surprises  have  presented  them- 
selves, which  have  been  described  and  delineated  b}^  Henle  and 
Tillaux,  the  self-contained  bistoury  of  Langenbeck  would  have 
slwfted  its  point  to  a  portion  of  the  trachea  less  beset  with  perils, 
and  there  have  completed  its  work.  One  of  less  experience  would 
do  well  to  avoid  such  a  region,  and  select  one  of  less  possible 
hazard;  and  a  reflective  study  of  the  various  sites  in  which  tra- 
cheotomy has  been  performed  leads  the  writer  to  select  that  of 
crico-tracheotomy ;  besides  the  commendation  of  this  site  by 
Hueter  and  other  authorities,  the  writer's  own  experience, 
embracing  a  series  of  sixty  tracheotomies,  confirms  this  choice. 

There  is  another  obstacle  which  often  confronts  the  surgeon 


tracheotomy;  broxchotomy.  1039 

on  the   threshold  of  his  purpose;  this  is  the  opposition  of  the 
parents  or  relatives  of  the  patient  to  the  operation  :  or  if  consent 
is  given,  it  is  often  at  so  late  a  stage  in  the  croupal  disease,  that 
the  work  is  in  vain.     Much  address  is  often  needed  to  overcome 
this  obstacle.     An  argument  sometimes  used  by  the  writer,  and 
which  usually  has  a  convincing  effect,  is  the  following:  Your  child 
will    die  within  a  few  hours,  unless  the  operation  be  done;   if 
done,  it  will  give  it  one  chance  in  four  of  saving  its  life ;  should 
it  die  uuoperated  on,  it  will  die  by  slow  strangulation;  the  child's 
condition  is  the  same  as  if  a  cord  encircled  its  neck,  which  is  being 
tightened  every  minute;   the  operation  proposed   will   cut  this 
cord  and  give  the  child  easy  breathing ;   and  if  this  be  done, 
though  the  child  may  not  be  saved,  it  will  render  its  death  an 
easy  one.     A  statement  of  this  purport  will  rareh''  fail  to  obtain 
permission  for  the  operation,  even  from  one  ignorant,  or  preju- 
diced against  surgical  work,     xlnd  should  these  arguments  still 
fail  of  purpose,  then,  as  occurred  in  a  case  which  the  author  saw, 
the  final  appeal  may  be  in  the  following  form :  I  offer  the  child 
a  reasonable  chance  for  saving  its  life;  if  you  deny  it  this  privi- 
lege, who  will  be  accountable  for  its  death?     Such  an  appeal,  as 
in  the  writer's  case,  extorted  a  reluctant  permission;  and  though 
the  case  ended  fatally,  yet  the  relief  obtained  by  the  operation 
was  so  marked,  that  the  obstinate  parent  found  no  cause  for 
regret  that  the  operation  had  been  done.     The  number  of  suc- 
cessful tracheotomies,  which  have  been  done  in  all  parts  of  the 
world  where  intelligent  surgery  exists,  has  now  nearly  banished 
the  prejudice  again.st  it,  with  which  the  old  generation  of  surgeons 
was  forced  to  contend,  and,  as  Trousseau  says,  it  "  must  hence- 
forth be  looked  upon  as  one  more  conquest  of  the  healing  art." 

To  perform  tracheotomy,  the  surgeon  should  have  a  properly 
lighted  room,  a  table  on  which  the  patient  will  rest,  assistants  in 
his  work,  and  a  small  number  of  instruments.  It  is  true  that  in 
an  emergency,  it  can  be  done  anywhere,  and  in  a  room  so  poorlv 
lighted  that  fingers  rather  than  eyes  will  do  the  seeing.  Under 
such  embarrassment  the  writer  has  been  forced  to  operate;  and 
with  perhaps  an  incompetent  assistant,  and  with  oitly  the  small- 
est instrumental  ecjuipment. 

If  there  be  time,  as  is  usually  the  case,  for  deliberate  prepara- 
tion, and  it  is  during  sunlight,  the  patient  should  be'  so  j^laced 
that  the  operator  will  not  overshadow  the  field  of  his  work :  that 
is,  his  shadow  should  fall  behind  him.  And  the  light  from  the 
southward  cpiarter  of  the  sky  will  be  better  tnan  that  from  the 


1U4U  J'JIAKY.NGKAL    AND    (liSuriiAUKAF.    NKOl'LASMS. 

northward.  Also  during  the  night,  the  patient  should  be  so 
placed  that  the  surgeon  and  his  aids  will  not  darken  the  opera- 
tive field.  In  case  the  room  has  a  central,  suspended  light,  the 
patient  should  not  be  placed  directly  under  it,  but  slightl}^  to  one 
side.  If  light  must  be  gotten  from  lamps,  these  should  be  placed 
on  a  small  table,  near  the  side  of  the  patient,  opposite  to  the  sur- 
geon. The  light  should  not  be  held  in  the  hand  of  an  assistant: 
lest  he,  fainting,  should  drop  his  light,  and  leave  the  room  in 
darkness,  as  occurred  once  in  the  author's  practice. 

An  operating  table  may  be  extemporized  by  placing  together 
two  or  three  small  stands  or  tables;  or  it  can  be  made  by  unhing- 
ing a  door  and  placing  this  on  two  stands,  or  small  tables:  and  if 
tables  be  used,  they  should  not  be  too  wide.  The  table  may  have 
as  covering,  a  quilt  or  blanket;  and  a  small,  hard  pillow  or  cush- 
ion must  be  provided,  which  placed  beneath  the  child's  neck  and 
shoulders  will  ui)lift  the  neck,  curve  the  head  backwards,  and 
expose  the  surface  to  be  operated  on. 

As  aids,  the  surgeon  should  have  one  to  administer  the 
ansesthetic,  one  to  sponge,  one  to  manage  the  retractors,  and  one 
to  arrest  or  control  any  irregular  movements  of  the  child.  As 
such  aids  may  not  be  present,  the  surgeon  if  he  has  had  experi- 
ence in  emergencies,  might  anpesthetize  the  patient,  and  then  do 
the  work  with  one  untrained  assistant;  or  if  he  has  learned  to 
operate  where  the  luxury  of  assistance  was  denied,  then  it  would 
be  possible  to  do  the  work  alone,  after  placing  the  child  in  com- 
plete aucesthetic  narcosis ;  yet  in  such  an  attempt,  one  would  run 
many  risks,  which  assistants  would  remove.  In  case  the  child  is 
nearly  moribund,  which  is  too  often  the  condition  present  w^ien 
surgical  aid  is  invoked,  then  anaesthesia  may  be  omitted,  since 
unoxygenated  blood  circulating  in  the  arteries  will  render  the 
tissues  nearly  insensible;  and  in  such  patient,  only  dark  venous 
blood  will  ooze  from  the  divided  sti'uctures;  and  as  the  incision 
is  being  made,  the  slight  movements  of  the  patient  will  clearly 
show  that  the  work  is  nearly  or  quite  painless. 

And  finally,  to  operate  with  ample  facility,  the  following 
instruments  should  be  at  hand  : — 

1.  A  sharp  pointed,  short-bladed  scalpel,  and  a  probe-pointed 
bistoury :,  and  these  two  may  be  contained  in  a  sheathing  handle 
similar  to  that  of  a  clasp-knife. 

2.  Two  blunt  retractors,  the  form  of  which  is  shown  in  Figure 
102.  Tiiese  instruments  have  two  points,  blunt  and  separated  a 
quarter  of  an  inch   from  each  otlier.     This  retractor  has  been  of 


TRACHEOTOMY ;  BROXCHOTOM Y. 


1041 


eminent  service  to  the  author;  it  serves  a  twofold  purpose:  for, 
besides  separating  and  holding  the  lips  of  the  wound  asunder,  it 
can  do  hemostatic  duty :  for,  as  soon  as  a  vessel  of  small  size  is 
opened,  the  retractor  can  be  so  shifted  that  one  of  its  tines  rests 
on,  and  compresses  the  vessel.  Such  pressure  made  by  lateral 
traction  will  control  ordinary  venous  bleeding :  but  if  an  artery 
be  opened,  it  would  be  safer  to  tie  it.  It  often  happens  that 
beneath  the  skin,  near  the  median  line,  the  surgeon  finds  one  or 
tw^o   anterior  jugular  veins,  which,  when   encountered,  can   be 


Figure  102.     Exhibiting  the  blunt  retractor. 

caught  by  the  retractor,  and  pulled  aside  from  the  point  of  the 
knife.  Of  all  the  instruments  which  the  writer  uses  in  the  oper- 
ation, he  places  the  highest  estimate  on  this  retractor:  it  is  an 
assistant  in  dilating  the  wound  and  controlling  bleeding;  and  it 
may  be  added,  that  it  is  no  small  aid  in  the  dissection:  for  with 
it  the  tissues  can  be  caught,  and  by  lateral  traction  separated 
from  the  subjacent  structure. 

3.  The  blunt  dissector,  shown  in  Figure  103:  to  this  instrument 
the  writer  assigns  a  position  in  importance  near  that  which  he  has 
given  to  the  retractor.     After  the  skin  has  been  divided,  with 


Figure  103.     Showing  the  form  of  the  blunt  dissector. 

this  instrument  the  subjacent  structures  can  be  separated  rapidly, 
and  almost  bloodlessly;  and  should  vessels  be  met,  they  can  be 
loosened  with  the  blunt  point,  caught  by  the  retractor,  and  pulled 
aside.  This  instrument  can,  in  a  great  degree,  replace  the 
scalpel  after  the  skin  has  been  divided.  It  is  of  special  use  in 
the  management  of  the  thyroid  gland,  should  this  part  encroach 
on  the  field  of  the  operator:  for  the  blunt  point  can  be  thrust 
under  the  margin  of  the  gland,  above,  below%  or  at  the  side,  and 
the  gland  then  pushed  away  so  that  the  trachea  can  be  exposed.. 


104"J  l'HAKYN(JKAI.    AND    (KSUl'ilAGKAl.    XKOI'LASM-S. 

The  gland  is  sometimes  very  closely  adherent  to  the  trachea ; 
and  even  in  that  case,  with  care  the  parts  can  be  separated;  and 
thus,  as  the  writer  has  done,  the  supra-thyroid  section  can  be 
extended  downwards  by  the  division  of  one  or  two  tracheal  rings, 
which  are  bridged  over  b}'  the  th3a'oid  gland. 

4.  Two  or  more  hiemostatic  forceps  should  be  at  hand,  with 
which  bleeding  vessels,  which  cannot  otherwise  be  controlled, 
may  be  seized  and  the  forceps  left  in  place  until  the  opening  has 
been  made,  provided  asphyxia  seems  imminent ;  if,  however,  the 
patient's  condition  will  permit,  let  the  vessel  be  tied,  and  the 
forceps  removed. 

5.  Thread  for  ligating  vessels  should  be  provided ;  also  a 
threaded  needle  for  suturing  a  portion  of  the  wound,  after  the 
canula  has  been  inserted.  And  for  removing  blood,  a  fine 
sponge  is  needed;  and  in  the  absence  of  this,  aseptic  mops,  or 
even  a  towel  or  soft  cloth,  will  suffice. 

6.  Some  instrument  should  be  provided,  with  which  the  semi- 
liquid  excreta  can  be  aspirated  from  the  opened  trachea ;  this 
may  be  a  soft  catheter  or  rubber  tube,  to  which  a  suction  bulb, 
or  tlie  suction  end  of  a  syringe,  has  been  attached.  This  suction, 
as  before  stated,  has  been  done  by  the  surgeon's  mouth:  and 
though  the  act  was  one  of  philanthropy,  it  also  proved  to  be 
one  of  fatal  rashness.  Recently,  in  England,  a  father  at  the 
suggestion  of  his  physician  extracted  with  his  lips  the  excreta 
from  the  wound  in  his  own  child,  and  became  infected  with 
diphtheria;  the  parent  instituted  legal  proceedings  against  his 
physician,  and  blind  Themis  turned  her  scale  against  the  latter, 
and  the  parent  recovered  heavy  damages.  It  is  fortunate  that  in 
the  web  of  common  humanity,  such  brutal  thread  has  rarely 
been  inwoven;  though  the  tooth  of  the  ingrate  is  sometimes  felt, 
yet  the  tear  of  gratitude  oftener  flows. 

7.  The  operator  should  have  an  assortment  of  double  canulte 
— at  least  three:  one  of  small  calibre,  another  of  medium  size,  and 
a  third  still  larger;  and  if  the  case  be  an  adult,  a  canula  of  the 
irreatest  diameter  will  be  needed.  A  form  of  canula  which  the 
writer  has  found  very  satisfactory  is  that  represented  in  Figures 
104  and  105.  The  canula  may  be  of  silver,  hard  rubber,  or 
aluminum;  that  of  aluminum  shares  with  that  of  rubber  the 
advantage  that  it  is  very  light,  and  hence  will  be  less  apt  to 
erode  than  one  of  silver.  That  of  silver  has  done  excellent  serv- 
ice for  the  writer;  and  within  his  experience  he  has  rarely  seen 
ulceration  arise  from  it.     A  more  important  thing  in  the  canula  is 


TRACHEOTOMY ;  BEONCHOTOM Y. 


1043 


that  it  should  be  solid  in  its  construction;  and  especially,  that  the 
horizontal  plate  to  which  the  outer  tube  is  attached  should  be  so 
firmly  fastened  that  the  two  cannot  separate:  or  if  motion 
between  the  two  has  been  provided  for,  as  is  the  case  with  that 
made  by  Luer  in  Paris,  then  this  connection  should  be  secure 
against  separation:  for  the  history  of  tracheotomy  contains 
records  of  several  accidents,  in  which  the  canula  descending  into 
the  trachea,  the  patient  had  the  double  calamity  of  having  coupled 


Figure    104.      Showing    the 
canula  of  usual  form. 


FiGUEE  105.     Showing  the  canula  with 
the  inner  tube  partly  withdrawn. 


with  his  croupal  trouble,  also  a  foreign  body  in  his  ai-r-passage ; 
and  this  has  descended  so  deep  as  to  be  inextricable.  In  a  case 
recently  published,  the  operator  was  so  fortunate  as  to  extricate 
the  tube  by  suspending  the  patient  with  head  downwards,  and 
then  striking  the  thorax,  when  the  tube  descended  and  was 
extracted. 

Morax,  who  measured  the  trachea  of  children  between  two 
and  fifteen  years  of  age,  finds  that  they  vary  from  three  and  one- 
half  to  seven  and  one-half  lines  in  diameter;  and,  of  assorted 
canulae,  he  would  have  four,  viz.,  one  of  three,  one  of  four,  one  of 
five,  and  one  of  six  lines  in  diameter. 

The  horizontal  plate  of  the  canula,  on  each  side  near  its  end, 
is  provided  with  orifices,  in  which  cords  are  to  be  tied,  and 
passed  around  the  neck,  and  tied  so  that  the  instrument  cannot 
be  dislodged. 

The  inner  tube  of  the  canula  is  fixed  and  held  in  the  contain- 
ing tube  by  a  kind  of  key  or  latch  which  is  fastened  to  the  hori- 
zontal plate,  and  can  be  so  turned  as  to  fix  or  release  the  inner 


1044  PHARYNGEAL    AND    (ESOPHAGEAL    NEOPLASMS. 

tube.  The  inner  tube  should  extend  downwards  somewhat 
bevond  the  outer  one.  The  canuhi  being  thus  constructed,  wlien 
it  becomes  obstructed  with  detritus  or  excreta,  the  containing 
ke}'  is  turned,  and  the  inner  tube  is  removed,  cleansed  and  again 
replaced.  The  outer  tube  is  provided  with  a  fenestra,  at  the  site 
of  its  greatest  curvature,  which  is  intended  to  let  the  air  pass 
through  the  larynx,  when  the  latter  becomes  permeable.  By 
means  of  this  ingenious  contrivance,  the  advance  of  the  patient 
towards  recovery  can  be  determined;  to  test  this,  let  tlie  inner 
tube  be  extracted,  and  then,  when  the  external  outlet  is  closed,  if 
the  larynx  be  free, the  patient  can  breathe  in  normal  manner;  if, 
however,  the  obstructing  agency  is  still  present,  breathing  will  be 
correspondingly  impeded,  and  phonation  absent. 

8.  Two  tenacula  should  be  present  for  seizing  and  fixing  the 
trachea  when  this  is  found  ;  the  work  can,  however,  be  done  with 
one;  yet  by  the  aid  of  two,  when  these  are  inserted  somewhat 
laterally,  the  tracheal  wound  can  be  made  between  them,  and  its 
lips  pulled  apart. 

9.  A  basin  of  aseptic  water  should  be  provided,  to  be  used  for 
cleansing  sponges  or  gauze  used  in  the  work.  Feathers  from  the 
wing  of  a  fowl  are  needed  for  cleansing  out  the  mucus  that  may 
lodge  in  and  obstruct  the  canula:  for  the  use  of  these  will  dispense 
with  the  frequent  removal  of  the  inner  tube. 

Many  tracheotomists,  particularly  Trousseau,  use  an  instrument 
specially  intended  for  dilating  the  wound  made  in  the  trachea; 
and,  in  the  absence  of  the  tenaculum,  such  an  instrument  might 
be  necessary;  but  with  two  tenacula,  and  the  aid  of  the  small, 
blunt  retractors,  the  dilatation  can  readily  be  done;  and  the 
work  being  done  in  this  manner,  the  surgeon  can  easily  extract 
the  morbid  material  from  the  opened  trachea.  The  writer  pre- 
fers the  method  in  which  the  wound  is  retained  open  with 
retractors  as  aid  in  extracting  the  false  membranes :  for,  in  the 
plan  advised  by  Trousseau,  there  is  danger  of  thrusting  the 
material  further  downwards. 

Such  is  the  equipment  for  the  sN'stematic  performance  of 
tracheotomy  when  the  operation  can  be  leisurely  done;  some- 
times, the  condition  of  the  patient  permits  no  formal  prepara- 
tion; only  prompt  action  can  baffle  death.  In  such  an  emer- 
gency {occasio pracep^)  the  writer  once  made  an  opening  with  a 
clasp  pocket  bistoury,  with  one  stroke,  and,  as  a  temporary 
substitute  for  a  canula,  a  silver  catheter  was  used.  In  such 
urgent  case  the    intuition  of  the  surgeon   will  usually  suggest 


tracheotomy;  bkoxchotomy.  1045 

means  and  manner  by  which  the  work  can  be  best  and  quickest 
done.  A  remarkable  example  of  how  difficulties  may  be  sur- 
mounted in  such  a  strait  is  that  of  an  American  pliysician  M'ho 
performed  tracheotomy  in  the  midst  of  a  forest,  while  on  a  hunt- 
ing expedition.  In  the  absence  of  a  canula,  he  constructed  one 
which  answered  the  purpose,  from  a  leaden  bullet,  which  he 
hammered  into  a  thin  sheet,  and  then  he  molded  this  into  the 
shape  of  a  canula. 

Whether  the  patient  should  be  anaesthetized,  will  depend  on 
his  condition;  if  he  be  cyanosed  or  near  complete  asphyxia,  an 
anaesthetic  is  unnecessary;  in  fact,  if  anaesthetized  he  would  run 
a  risk  of  dying  during  the  operation;  but  previous  to  the  cya- 
notic stage,  the  mixed  anaesthetic  or  ether  should  be  given;  as 
t!jus,  the  j)atient  will  be  spared  pain;  and  what  is  more,  the 
slumber  of  ansesthesia  will  relieve  him  of  terror.  But  in  the 
partly  asphyxiated  child,  both  mentality  and  sensibility  are  so 
depressed,  that,  as  the  writer  has  witnessed,  scarcely  a  struggle 
will  be  made  while  the  knife  is  dividing  the  cervical  structures. 

The  patient,  surgeon,  assistants,  and  instruments  next  take 
their  respective  positions:  the  patient  on  the  table  with  nucha 
and  upper  part  of  the  shoulders  so  uplifted  as  to  bring  the  front 
of  the  neck  into  prominent  relief;  the  surgeon,  with  his  instru- 
ments near  his  right  hand,  must  stand  on  the  right  side  of  the 
patient,  so  that  in  using  the  knife,  the  incision  will  proceed 
downwards.  An  assistant  will  stand  behind  the  head  and  main- 
tain this  fixed,  with  the  chin  turned  backwards  so  that  the  latter 
will  not  be  in  the  surgeon's  way;  but  in  this,  the  skin  of  the' 
neck  must  not  be  displaced  from  its  normal  site,  lest  the  median 
line  be  shifted  to  one  side. 

Another  assistant  should  stand  so  that  he  can  hold  the 
lower  extremities;  and  if  the  child  be  small,  this  aid  can  easil}' 
hold  both  arms,  and  legs;  in  doing  which  he  stands  on  the  side 
opposite  to  the  surgeon,  and  resting  his  left  arm  across  the  child's 
knees,  he  grasps  the  latter's  right  hand,  and  pulls  it  downward, 
while  with  his  right  hand  he  draws  the  patient's  left  arm  down- 
wards, alongside  of  the  trunk  :  and  thus  held,  the  patient's  arms 
will  not  disturb  the  surgeon's  work.  Another  assistant  must  aid 
in  holding  the  retractors.  This  aid  should,  if  possible,  be  one 
who  has  had  some  training  in  such  service;  if  such  a  person  is 
not  at  hand,  the  surgeon  must  choose,  from  those  present,  some 
one  who  may  appear  to  have  the  best  requisites  for  such  duty. 

After  the  instruments  have  been  rendered  pure,  and  the  sur- 


1040  PHARYNGEAL    AND    CESOPHAfJKAL    NEOPLASMS. 

face  to  be  incised  lias  been  sponged  well  with,  first  an  alkaline, 
and  then  an  alcoholic  solution,  the  operation  begins  by  an 
incision  made  exactly  in  the  median  line,  the  cut  beginning  just 
above  the  cricoid  cartilage  and  extending  well  towards  the  sternal 
manubrium.  And  that  the  median  line  shall  not  be  deviated 
from,  it  is  well  first  to  trace  it  with  an  aniline  pencil;  for  if  this 
precaution  is  not  taken,  though  the  scalpel  may  start  right  it 
may  stray  from  the  intended  route  and  end  on  one  side;  and 
this  deviation  is  oftenest  towards  the  surgeon. 

There  are  advocates  of  rapid  work,  in  which  the  opening  is 
made  with  one  continuous  stroke;  prominent  among  these  is  St, 
Germain,  who  has  operated  thus  many  times,  and  successfully. 
His  method  is  to  seize  the  trachea  between  the  thumb  and  fingers 
of  the  left  hand,  and  then,  with  one  or  two  strokes,  to  enter  the 
air-passage,  and,  immediately  after  this,  insert  the  canula.  A 
practical  hand,  like  that  of  the  Parisian  })rofessor,  might  safely 
do  this,  but  ere  the  operator  could  acquire  such  deft  precision,  it 
is  probable  that  more  than  once  the  point  of  his  instrument 
would  pass  the  forbidden  mete  beneath,  and  enter  the  cesophagus: 
an  error  which  would  insure  a  fatal  result.  Hence  the  writer 
does  not  commend  this  method ;  audit  should  only  be  resorted 
to  where  imminence  of  death  forbids  deliberate  work.  Trousseau, 
whose  pen  and  scalpel  have  given  tracheotomy  a  place  in  sur- 
gery, directs  that  the  w^ork  be  done  as  follows:  "I  cannot  insist 
too  nmch  on  the  necessity  of  incising  the  tissues,  layer  by  layer, 
and  of  separating  the  vessels  and  muscles  with  blunt  hooks;  and 
thus  proceeding,  to  fully  lay  tlie  trachea  bare  before  opening  into 
it;  I  insist  on  the  absolute  necessity  of  working  slowly;  and  if, 
during  the  work,  the  child  becomes  suffocated,  then  cease  for  a 
moment,  and  let  it  struggle,  and  sit  up  until  it  regains  its  breath  ; 
and  though  a  minute  may  thus  be  lost,  this  is  not  to  be  feared. 
I  have  never  seen  slowness  cause  an  accident ;  but  I  have  often 
witnessed  difficulties  and  peril  from  doing  the  work  too  rapidly, 
even  though  the  work  were  done  by  an  adroit  operator." 

The  difficulties  sometimes  encountered  will  be  slight  in  the 
child  w'liose  neck  is  long,  and  in  whom  the  structures  lying  in 
the  trachea  are  thin;  in  such  a  case,  as  soon  as  the  skin  is 
divided,  one  is  near  the  trachea;  and  if  the  wound  is  then  dilated 
by  the  retractors  held  by  the  assistant,  the  surgeon,  using  the 
blunt  dissector,  can  easily  pierce  and  separate  the  thin  structures 
which  lie  on  the  trachea;  and  the  retractors  can  aid  in  this  dis- 
section.    And  when  tlie  trachea  is  reached,  it  will  be  recognized 


tracheotomy;  beonchotomy.  1047 

by  the  white  color  of  the  rings;  and  these  are  distinguishable 
from  each  other  by  the  tissue  of  pinkish  liue  which  connects  the 
rings  together.  And  wlien  the  trachea  has  been  sufficiently  dis- 
played, the  surgeon  transfixes  it  longitudinally,  somewhat  aside 
from  the  median  line,  with  the  tenaculum,  and  commits  this 
instrument  to  the  hand  of  the  aid  who  held  the  retractors:  and 
the  surgeon  next  transfixes  the  trachea  on  his  side  with  a 
tenaculum,  and  holds  this  in  his  left  hand.  AVhile  the  tenac- 
ula  are  thus  held,  the  surgeon  pierces  the  wall  vertically,  and 
then  continues  the  incision  downwards  until  three  rings  are 
divided.  Or  if  the  cricoid  cartilage  be  divided,  then  it  will 
suffice  to  sever  two  tracheal  rings.  And  this  longitudinal  open- 
ing should  be  made  with  blunt  scissors  or  with  a  probe-pointed 
bistoury,  as  extension  of  the  first  aperture  made,  and  it  must 
lie  in  the  median  line;  if  not,  the  inserted  canula  will  be 
defiected  to  one  side. 

The  writer  commonly  uses  but  one  transfixing  tenaculum; 
yet  in  cases  of  urgency,  he  has  found  that  greater  expedition  can 
be  made  with  two  tenacula,  since  by  their  aid,  as  soon  as  the 
trachea  is  opened,  the  lips  of  the  incision  can  be  drawn  laterally, 
and  air  thus  quickly  admitted. 

As  soon  as  the  incision  is  made  into  the  trachea,  air  gushes 
forth,  carrying  with  it  blood,  mucus,  and  perhaps  false  membrane; 
and  this  material  often  bespatters  the  surgeon's  face  and  dress. 
And  as  the  disease  has  thus  been  communicated,  the  prudent 
operator,  at  the  m.oment  when  he  makes  the  opening,  may  direct 
his  assistant  to  hold  a  cloth  which  may  receive  the  expelled 
matter:  or  the  operator's  open  hand  may  be  so  held  as  to  receive 
it.  The  first  expiratory  effort  forces  out  the  most  of  the  semi- 
liquid  material;  but  if  there  be  bleeding,  as  often  happens  from 
the  wounded  mucous  membrane,  then  this  blood,  flowing  into 
the  tube,  causes  coughing,  and,  at  short  intervals,  the  blood  is 
expelled  through  the  tracheal  incision.  The  opening  being- 
completed,  the  free  supply  of  air,  like  magic,  relieves  the  agony 
of  the  patient;  and  the  relief  is  such  that  the  unangesthetized 
child  ceases  to  struggle,  and  is  content  with  what  has  been  done. 
The  lips  of  the  wound  are  now  to  be  held  asunder,  while  the 
interior  of  the  trachea  is  examined  and  freed  of  any  obstructing 
material,  visible  or  accessible;  and  for  this  purpose,  both  forceps 
and  an  aspirating  tube  are  to  be  used.  When  the  passage  has 
been  made  clear,  the  canula  is  to  be  introduced.  In  the  subject 
of  thin  neck,  in  which  the  work  is  here  supposed  to  be  done,  this 


1U48  rilAKYXGEAL    AND    (JOSOPH A(;1:AL    XKOIM.ASMS. 

insertion  is  easily  accomplished  through  the  dilated  wound.  The 
canula  should  be  of  a  calibre  which  will  quite  fill  the  trachea: 
neither  too  large,  lest  it  erode;  nor  too  small,  lest  it  be  too 
movable,  and  be  inadequate  for  the  transmission  of  the  due 
amount  of  air  for  normal  breathing.  The  moment  the  canula 
enters,  it  generally  causes  a  momentary  irritation,  and  a  spasm 
of  coughing  ensues ;  if,  however,  the  patient  has  been  aniesthetized, 
or  is  in  a  cyanosed  state,  this  spasm  of  coughing  may  not  appear. 
The  introduction  of  the  canula  is  always  an  easy  matter,  if  a 
free  opening  has  been  made,  and  the  lips  of  the  wound  be  held 
well  asunder;  and  when  it  is  inserted, the  pieces  of  tape,  which 
are  fastened  to  the  fenestrse  of  the  horizontal  plate,  must  be 
carried  around  the  neck  and  tied;  and  this  knot  should  be  on 
one  side,  so  that  it  will  be  easily  accessible.  This  tying  should 
be  so  done  that  it  will  surely  hold;  also,  the  tapes  should  be 
neither  loose  nor  tight;  for  if  tight,  the  constriction  will  interfere 
with  the  circulation  of  the  head;  and  if  loose,  the  canula  may 
slip  from  its  place  in  the  trachea. 

When  the  canula  has  been  inserted  and  fixed  securely  in  its 
place,  the  wound  must  be  closed  by  suturing,  either  above  or 
below;  and  then  to  prevent  friction  of  the  parts  by  the  horizontal 
plate,  there  should  be  placed  a  strip  of  rubber  adhesive  plaster 
underneath.  The  work  being  completed,  the  patient  is  next 
removed  to  his  bed,  and  the  head  laid  low.  The  head  should  lie 
on  a  very  low  pillow;  for  if  the  usual  thicker  one  be  used,  there 
is  a  risk  that  the  patient's  chin  will  encroach  on  and  obstruct  the 
canula. 

The  tracheotomy  on  the  patient  just  described,  in  which  the 
anatomical  conditions  rendered  the  operation  a  very  simple  one, 
is  so  absolutely  free  from  difRculties  that  the  young  operator,  to 
whom  such  a  case  has  fallen,  may  conclude  that  the  difficulties 
and  obstacles  enumerated  by  writers  as  confronting  the  surgeon 
are  exaggerated;  this  opinion,  however,  will  receive  severe 
correction,  should  his  next  patient  be  a  child  of  short,  thick 
neck.  In  a  child  of  such  conformation  the  shortness  of  the  neck 
renders  but  a  small  portion  of  the  trachea  accessible;  in  fact,  the 
larynx  will  occupy  tlie  middle  third  of  the  neck,  and  being- 
buried  there  beneath  a  thick  adipose  stratum,  it  runs  much  peril 
of  being  inadvertently  injured.  In  such  a  patient,  the  voice 
would  be  irretrievably  lost,  were  the  scalpel  to  divide  the  vocal 
chords  b}'  a  rash  thrust;  but  if  the  M'ork  be  done  leisurely,  such 
accident   may  be   avoided.     In   a   patient  of  the  conformation 


*  TRACHEOTOMY;  BEOXCHOTOMY.  1049 

referred  to,  the  nucha  should  be  well  uplifted,  and  the  head 
turned  so  backwards  as  to  lift  the  air-passage  upwards  to  the 
greatest  possible  extent.  The  child  thus  placed,  an  incision 
should  be  made  in  the  median  line  of  the  neck,  embracing  the 
second  and  third  fourths  of  the  front  of  the  neck.  The  knife, 
held  vertically,  is  passed  through  the  skin;  then  being  inclined, 
it  is  carried  downwards.  The  skin  being  divided,  close  to  the 
median  line,  theanterior  jugular  veins  are  sometimes  found;  and 
these  swell  to  such  a  volume  as  to  present  a  formidable  appear- 
ance to  the  untrained  operator.  These  veins  may  be  tied:  a 
precaution  that  is  seldom  necessary;  but  instead,  one  may  catch 
them  both  with  the  retractor,  and  draw  them  to  one  side;  or  the 
veins  may  be  separated,  and  one  pulled  to  one  side,  and  one  to 
the  other.  The  incision  and  dissection  now  proceed  with 
cautious  steps  towards  the  trachea;  and,  first  of  all,  the  operator 
must  now  determine  accurately,  what  is  before  him.  For 
example,  he  may  find  that  a  portion  of  the  thyroid  cartilage  lies 
in  the  way  which  he  had  intended  to  traverse  with  his  knife; 
then  the  field  of  work  must  be  shifted  downwards.  The  palpat- 
ing index  can  now  feel  vvhat  it  could  not  do  through  the  intact 
skin.  Every  care  must  be  used  to  continue  the  backward  incision 
in  the  sagittal  or  median  plane;  and  this  is  not  difiicult  if  the 
initial  cut  was  correct;  and  even  if  this  was  wrongly  made 
through  displacement  of  the  skin,  it  is  not  too  late  to  correct  it; 
for  then  the  knife  can  be  shifted  to  the  right  or  left,  as  may  be 
required. 

In  the  course  of  the  deepening  incision,  veins  are  often 
encountered,  which  traverse  the  adipose  structure;  these  can 
usually  be  displaced  with  the  blunt  dissector,  and  held  aside  with 
the  point  of  the  retractor;  or  this  failing,  the  vessels  may  be 
tied.  The  thick  couch  of  adeps,  including  the  superficial  and 
middle  cervical  fasciae,  being  severed,  the  trachea  is  sometimes 
reached  without  any  further  impediment:  such  good  fortune, 
however,  is  rare;  normal,  or  anomalous  thyroidean  structure 
often  interposes  a  perilous  barrier  to  further  progress  of  the  knife; 
and  what  further  intensifies  the  gravity  of  the  occasion  is,  that 
the  dyspnoea  is  rapidly  becoming  more  oppressive:  a  condition 
that  urges  expedition;  and  audibly  admonishes  the  operator  "It 
were  well  it  were  dorie  quickly."  In  such  contingency,  if  the 
child  is  ceasing  to  breathe,  the  knife  should  be  urged  amain,  and 
borne  quickly  athwart  visible  and  invisible  obstacles,  until  an 
opening  is  made  through  which  the  cauula  can  be  inserted. 
67 


1050  PHAKYXGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

And  if,  ill  this  deep  cutting,  vessels  be  opened  which  bleed  freely, 
the  patient  should  be  quickly  turned  on  his  side,  so  that  the 
blood  can  escai)e  from,  and  not  flow  into,  the  tracheal  opening. 
In  thus  doing,  though  for  an  in.stant  death  may  ai)[)ear  to  have 
won  the  victory,  yet,  as  the  writer  has  witnessed,  breathing  may 
recommence;  and  this  has  the  effect  to  lessen  or  arrest  the 
hsemorrhage.  Should  bleeding  from  an  artery  continue,  this 
must  be  caught  and  tied. 

But  should  the  patient's  condition  be  less  pressing  and  admit  of 
deliberate  action,  and  if  the  thyroidean  structure  be  found  in  the 
way,  whether  isthmus  or  anomalous  lobe,  this  should  be  loosened 
from  the  trachea  with  the  blunt  dissector,  and  drawn  away  from 
the  rings  which  must  be  divided.  Should  this  displacement  not 
be  possible,  then  let  the  structure  be  grasped  by  two  pairs  of 
clasp-forceps,  and  divided  between ;  and  should  bleeding  follow 
the  removal  of  the  forceps,  then  each  portion  must  be  tied. 

In  the  deej)er  part  of  the  incision,  besides  the  thyroidean 
structure  mentioned,  anomalous  vessels,  if  they  exist,  will  be 
encountered :  and  the  most  common  one  is  the  middle  thyroid 
artery,  which  is  so  frequent  that  the  surgeon  may  reasonably 
expect  to  soon  meet  it  in  his  operations.  Should  this  be  found,  it 
must  be  doubly  tied  and  divided.  More  formidable  vessels,  as 
the  carotid,  the  subclavian  or  the  innominate,  may  confront  and 
call  the  knife  to  a  sudden  halt.  The  discovery  of  such  an  anom- 
aly would  compel  the  surgeon  to  shift  the  site  of  his  work  to  a 
higher  point,  viz.,  the  crico-thyroidean  space,  the  cricoid  carti- 
lage, and  the  uppermost  tracheal  ring.  And  should  this  route  be 
deemed  impracticable,  then  one  could  resort  to  the  bloodless 
method  of  intubation. 

In  regard  to  the  manner  of  opening  the  trachea  when  this  is 
reached,  something  more  should  be  said  than  what  has  already 
been  stated:  for  authorities  here  differ.  Some  operators  discard 
all  instruments  of  fixation,  and  do  this  by  seizing  the  exposed 
trachea  between  the  thumb  and  index.  The  objection  to  this 
plan  is  that  there  is  not  sufficient  room  for  the  insertion  of  the 
fingers;  and,  hence,  the  trachea  would  be  compressed,  and  robbed 
of  some  of  its  space,  so  precious  to  the  suffocating  patient.  Trous- 
seau pressed  his  finger  nail  against  the  upper  surface  of  the 
trachea,  and  used  this  as  a  guide  in  making  the  first  incision  into 
the  trachea.  Archambault,  the  favorite  pupil  of  Trousseau,  hav- 
ing reached  and  verified  the  trachea  with  the  index  finger,  rests 
this  on  a  tracheal  ring,  and  then  carries  the  knife  down  on  the 


tracheotomy;  broxchotomy.  1051 

volar  side,  and  thus  makes  the  first  puncture.  He  counsels  to 
touch  lightly;  for  the  less  the  pressure  is,  the  less  apt  is  the  knife 
to  stray  from  the  proper  track.  He  totally  discards,  in  a  flippant 
line,  the  use  of  a  fixing  tenaculum.  It  is  true  that  the  opening 
can  thus  be  made :  and  the  writer  has  so  done  it;  but,  by  so  doing, 
one  loses  the  control  of  the  trachea  at  a  moment  when  such  con- 
trol is  so  needful.  During  this  most  eventful  moment  in  the 
work  of  tracheotomy,  the  forcible  respiratory  movements  carry 
the  trachea  upwards  and  downwards;  and  these  movements  are 
increased  in  the  un anaesthetized  child  by  the  terror  awakened  by 
the  whistling  sound  of  the  air  entering  or  escaping  from  the  first 
puncture.  In  such  an  anxious  moment,  when  neither  delay  is 
allowed,  nor  error  permitted,  and  the  arbitrament  of  a  life 
depends  on  faultless  action,  nothing  can  so  exempt  the  young 
operator  from  disorderly  confusion,  nor  so  maintain  the  unper- 
turbed coolness  acquired  by  the  tuition  of  experience,  as  to  be 
able  to  hold  and  accurately  fix  the  trachea,  when  the  opening- 
through  its  wall  is  being  made.  And  in  no  way  known  to  the 
writer  can  this  be  more  surely  and  well  done,  than  with  a  tenac- 
ulum of  well-curved  point,  which  has  been  inserted  into  the 
trachea  longitudinally,  alongside  of  the  point  where  the  opening 
is  to  be  made.  And  still  greater  advantage  will  be  given  by  the 
use  of  two  such  instruments;  the  second  one  being  inserted  paral- 
lel with  the  first,  on  the  other  side:  for  with  these  the  trachea  is 
easily  steadied  and  fixed;  and  when  the  incision  is  made,  the 
tenacuia  can  be  used  as  lateral  retractors,  by  means  of  which  the 
tracheal  wound  can  be  laterally  opened  so  that  an  ample  current 
of  air  can  enter  the   air-passage. 

Instead  of  tenacuia,  Trousseau,  Archambault  and  many 
eminent  tracheotomists  use  a  dilator,  wliich  is  inserted  into, 
and  made  to  widen  the  tracheal  fenestra  as  soon  as  this  is 
made.  Archaml)ault  and  his  great  master  expatiate  on  the 
utility  of  this  instrument:  yet  it  has  the  unavoidable  disadvan- 
tage that  it  may  catch  and  carry  with  it  the  pseudo-membrane, 
which,  when  present,  it  is  so  desirable  to  remove.  But 
with  the  tenacuia,  besides  dilating  the  new-made  window  for  the 
free  admission  of  air,  the  operator  can  also  retain  this  patent 
until  the  obstructing  material  has  been  removed;  it  would  be 
impossible  to  extract  this  successfully,  if  the  passage  were 
obstructed  with  a  dilating  instrument.  An  objection  urged 
against  the  tenaculum  is  that  it  wounds  the  tracheal  wall;  in 
reply,  the  writer  would  state,  that  from  repeated  employment  of 


10")2  i'iiai:yn(;kal  and  (esophageal  neoplasms. 

the  iiistramont  in  traclieotomy,  he  has  seen  no  had  effects  follow 
its  use. 

When  the  opening  has  been  made,  and  the  trachea  freed  from 
visible  or  accessible  obstruction,  then  conies  the  important  act  of 
introducing  the  canula.  Diflerent  methods  of  doing  this  have 
been  adopted.  Archambault  used  his  index  finger  as  a  guide, 
which  being  inserted  into  the  wound,  the  canula  is  carried  down 
on  the  palmar  side,  and,  as  this  is  done,  the  finger  is  withdrawn 
and  the  canula  slipped  into  its  place.  The  objection  to  this  plan 
is,  that  in  so  doing  the  trachea  is  wholly  closed,  and  breathing 
arrested  for  a  moment  or  two:  a  serious  fault.  Guersant,  to  insure 
against  failure  which  has  occurred  in  the  introduction,  inserted  a 
flexible  male  catheter  into  the  tracheal  wound,  and  over  this  the 
canula  was  passed.  Others  have  devised  and  used  a  guiding 
instrument  of  smaller  dimensions  than  a  catheter.  If  the  wound 
be  opened  by  tenacula,  no  such  guide  is  needed :  for  the  lower  end 
of  the  canula  is  pas.sed  into  the  well-opened  wound  and  carried 
straight  backwards;  and  as  soon  as  it  reaches  the  posterior  wall, 
the  outer  end  is  uplifted  and  carried  backwards  through  the  arc  of 
a  circle,  while  the  inferior  end  descends.  The  contact  with  the 
mucous  membrane  often  causes  a  fit  of  coughing,  which  will  soon 
subside  if  the  instrument  be  held  in  place.  As  soon  as  the  canula 
is  in  place,  the  tapes  attached  to  it  are  to  be  passed  around  the  neck 
and  tied  ;  and  this  done,  the  tenacula  may  be  removed.  If  the 
tenacula  be  removed  too  early,  there  is  danger  that  the  canula 
may  be  expelled  in  a  fit  of  coughing,  and  the  operator  be  much 
embarrassed  to  reinsert  it.  Such  accident  cannot  occur  if  the 
tenacula  remain  in  place  until  the  canula  has  been  secured  by 
tying.  Should  the  canula  be  accidentally  dislodged,  then  the 
ins})iratory  effort  will  close  the  outer  wound,  and  the  child  will 
get  but  little  air  until  the  wound  is  reopened,  which  may  be  done 
with  the  retractors  used  in  making  the  incision.  Also,  from  the 
struggles  of  the  child,  the  wound  may  again  bleed;  yet  the  inci- 
sion, thus  hidden  from  view,  may  be  opened  with  the  retractors, 
when,  if  possible,  one  side  of  the  tracheal  cut  should  be  caught 
with  a  tenaculum  or  forceps,  and  so  pulled  aside  that  the  canula 
may  be  replaced.  But  if  this  plan  fails,  then  a  finger  should  be 
introduced  through  the  wound  into  the  air-passage,  and  the 
canula  carried  quickly  along  the  volar  side  into  the  trachea. 

When  the  primary  oj)ening  has  been  made  in  a  subject  in 
which  the  structures  are  thick,  if  a  fixing  tenaculum  has  not  been 
used,  the   difficulties  just  recounted  may  be  met;    and   in  the 


tracheotomy;  broxchotomy.  1053 

attempt  to  insert  the  canula,  the  entering  end  of  the  canula  may 
catch  on  the  front  wall,  and,  instead  of  passing  into  the  trachea, 
it  may  be  forced  down  in  front  of  it.  And  this  mistake  has  been 
an  occasional  cause  of  death  during  the  operation:  an  accident 
that  would  have  been  avoided,  had  the  operator  first  secured 
control  of  the  trachea  with  the  tenaculum  before  opening  it. 

Another  occasional  complication  of  serious  nature  is  haemor- 
rhage, just  as  the  final  opening  is  being  made:  and  this  may  be 
caused  by  the  opening  of  a  large  vein,  or  by  division  of  thyroi- 
dean  structure.  Or  an  artery  may  be  opened,  and  in  this  case, 
the  bleeding  will  be  in  jets.  No  vessel  of  size  should  be  severed 
before  it  is  ligated;  to  do  otherwise  could  only  be  justified  by 
extreme  asphyxia  and  imminent  death.  And  even  then,  before 
incising  vascular  structure,  or  dividing  a  vessel,  the  precaution 
should  be  taken  to  catch  with  clasp  forceps  on  each  side,  and  then 
sever  between  them. 

Most  authorities  teach  that,  when  asphyxia  impends,  the 
operator  should  hasten  to  conclude  the  opening,  and,  though 
minor  vessels  or  vascular  structure  be  in  the  way,  he  should 
open,  at  once,  through  these  into  the  trachea.  It  is  claimed  that, 
by  so  doing,  the  bleeding  will  cease  as  soon  as  the  canula  is 
inserted  and  respiration  is  freely  restored.  This  doctrine  is 
fallacious,  as  has  more  than  once  been  verified  by  the  author's 
experience;  for  if  an  artery  is  opened,  it  will  surely  continue  to 
bleed  until  tied,  twisted,  or  its  mouth  is  stopped  with  a  clot. 
And  a  mesh  of  th^^roid  veins  being  severed,  the  little  sheet  of 
blood  thence  flowing  will  continue  for  a  brief  time,  despite  the 
tracheal  opening;  and,  also,  large  thyroid  veins  being  cut  will 
continue  to  bleed.  Free  breathing  accelerates  the  circulation;  it 
does  not  slacken  it ;  the  inspiratory  effort  attracts  the  venous 
blood  towards  the  heart:  facts  well  known  to  the  practical 
surgeon.  Hence,  before  dividing  vascular  structure,  it  is  safer  to 
include  it  in  a  circumscribing  ligature,  or  catch  it  in  clasp 
forceps  and  subject  it  to  compression  or  torsion,  until  the  vessels 
are  closed. 

In  case  of  parenchymatous  bleeding,  control  of  this  is  some- 
times obtained  by  the  pressure  of  the  canula ;  and  to  get  this  action, 
the  canula  should  be  in  close  contact  with  the  contiguous  wound. 
In  such  a  case  it  is  advised  to  remove  the  canula  and  replace  it 
by  one  somewhat  larger,  which  will  completely  fill  the  wound  in 
the  trachea.  The  wound  usually  bleeds  most  from  the  upper 
angle,  owing  to  the  greater  pressure  of  the  canula  on  the  lower 


1054  PHARYNGEAL    AND    (JCSOPHAGEAL    NEOPLASMS. 

portion;  hence  some  aid  can  be  derived  from  passing  a  suture 
through  the  sides  of  the  wound  above  ti)e  canuhi,  so  as  to  lessen 
the  wound ;  thus  doing,  the  writer  lias  more  than  once  controlled 
bleeding.  The  use  of  the  solution  of  the  chloride  or  sulphate  of 
iron,  as  a  styptic  to  arrest  bleeding  in  tracheotomy,  is  oi)posed  by 
all  autliorities;  for  the  agent,  in  its  work  of  coagulation,  forms  a 
soft  compound  tliat  can  readily  enter  the  trachea,  to  the  ulterior 
detriment  of  the  patient.  And  it  may  be  said  of  the  use  of  such 
agent,  employed  here  or  elsewhere,  that  though  the  bleeding  is 
thus  arrested,  the  evil  hour  is  only  postponed:  for,  when  the  coag- 
ulum  is  detached,  bleeding  sometimes  ensues;  and  the  parts  are  in 
an  ill  state  for  healing,  since  the  salt  of  iron  acts  as  an  escharotic. 

When  blood  from  the  wound  has  entered  the  lungs,  in  even 
moderate  amount,  it  interferes  with  bleeding;  and,  in  a  subject 
that  is  partly  asphyxiated,  this  added  trouble  can  quickly  end 
life;  hence,  such  blood  should  be  removed.  As  the  writer  has 
verified,  the  titillation  of  the  mucous  membrane  of  the  trachea 
below  the  wound  sometimes  causes  an  expulsive  effort,  which 
brings  the  blood  up,  and  frees  the  lungs,  so  that  breathing  is 
easy.  The  aspiration  of  such  blood  by  the  mouth  of  the  operator 
brings  peril  to  the  surgeon  rather  than  relief  to  the  patient,  since 
the  aspiration  could  only  be  done  imperfectly  by  oral  suction. 
As  already  indicated,  an  elastic  tube  with  suction  balloon  would 
do  the  work  better.  Or  in  the  absence  of  this,  a  soft  catheter 
attached  to  the  suction  point  of  a  syringe  might  be  employed. 

In  the  haste  sometimes  demanded  in  the  operation,  the 
surgeon  finds  that  his  incision  is  ill  placed  in  the  trachea: 
instead  of  being  in  the  median  line,  it  is  in  the  side  of  the  canal: 
or  commencing  in  the  median  line  of  the  trachea  it  may  have 
diverged  somewhat  towards  the  right  or  left  side.  In  the  second 
case,  the  error  of  place  will  not  interfere  much  with  the  use  of 
the  canula,  since  the  outer  end  of  the  latter  will  be  near  its 
proper  site.  But  if  the  tracheal  incision  be  wholly  on  the  side, 
its  ill  position  will  so  interfere  with  the  use  of  the  canula  that 
authorities  counsel  to  make  a  new  opening,  parallel  with  the 
preceding  one.  In  making  this  new  opening,  the  error  has  been 
committed  of  carrying  the  new  cut  into  the  first  one  and  form- 
ing a  movable  spur  in  the  front  wall  of  the  trachea.  If  this  be 
done,  it  would  interfere  with  the  subsequent  form  of  the  trachea, 
when  the  wound  lias  healed.  And,  again,  should  no  spur  be 
made,  there  is  still  the  risk  that  the  narrow  bridge-like  slip  of 
cartilage  between  the  two  incisions  may  die,  and  thus  leave  a 


teacheotomy;  broxchotomy.  1055 

breach  in  the  wall  of  the  trachea,  whence  stenosis  of  the  canal 
vYOuld  remain  after  healing.  Hence,  the  writer  advises  to  use  the 
lateral  slit  when  this  has  inadvertently  been  made,  rather  than 
to  attempt  to  form  a  new  one;  thus  doing,  though  the  canula 
deviates  to  one  side,  a  satisfactory  result  has  been  obtained  by  the 
writer. 

A  more  serious  error  is  that  of  perforating  the  posterior  wall 
of  the  trachea,  and  probably  entering  the  oesophagus.  A  mere 
perforation  of  the  wall  might  cause  no  trouble;  but  should  the 
oesophagus  be  opened,  the  condition  would  be  a  very  serious  one, 
since  in  the  swallowing  of  food,  especially  that  which  is  liquid, 
a  portion  of  the  same  would  enter  the  trachea  and  pass  to  the 
lungs.  Such  a  complication  would  almost  certainly  cause  death. 
As  a  means  of  rescuing  the  patient,  one  might  resort  to  alimen- 
tation through  an  oesophageal  tube;  thus  treated,  the  patient 
would  have  a  chance  for  recovery,  which  otherwise,  would  be 
denied  him. 

The  emphysematous  infiltration  of  the  air  into  the  surround- 
ing tissues  is  an  occasional  occurrence;  it  has  been  observed  a 
few  times  by  the  writer  in  his  operations.  It  disappeared  with- 
out treatment.  The  case  might  be  otherwise,  were  tlie  emphysema 
to  arise  from  the  mouth  of  the  canula  becoming  so  buried  in 
the  wound  that  the  expired  air  could  not  escape,  but  would  enter 
the  structures  which  rest  on  the  outlet  of  the  canula.  This 
condition  may  arise  from  swelling  of  the  wound:  and  then  to 
prevent  infiltration  of  air,  a  longer  tube  must  be  used.  And  as 
a  further  aid,  the  surface  of  the  w^ound  may  be  covered  with  a 
coating  of  collodion.  Any  attempt  to  remove  air  which  has  once 
entered  the  tissues  of  the  neck  will  prove  futile.  Left  to  itself,  it 
will  spontaneously  vanish. 

Should  a  case  occur  in  which  there  is  an  intolerance  of  the 
canula,  then  some  other  method  of  maintaining  the  tracheal 
wound  open  must  be  resorted  to.  In  such  a  patient,  the  writer 
made  two  incisions  in  each  side  of  the  tracheal  cut,  which  so 
converged  that  a  thread  could  be  tied  to  each  side,  and  the  sides 
pulled  laterally,  so  as  to  hold  the  wound  open.  In  this  way  the 
wound  was  easily  maintained  j^atulous  for  almost  a  week. 

The  operation  having  been  completed,  the  patient  is  placed 
in  bed,  with  the  head  low,  so  that  the  chin  will  not  obstruct  the 
canula:  and  the  mouth  of  this  may  be  left  uncovered;  or  there 
may  be  placed  over  it  a  few  layers  of  thin  gauze.  The  covering 
of  the  outlet  of  the  canula  with  gauze  is  highly  recommended  by 


1056  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

Trousseau.  He  claims  that  this  muffling  screen,  becoming  warm 
and  moist,  prepares  the  air  for  admission  to  the  hmgs,  in  the 
same  manner  as  if  it  were  breathed  through  the  mouth  or  nose. 

Special  attention  should  be  given  to  maintaining  the  air  of 
the  chamber  at  a  uniform  temperature;  and  for  this  purpose  a 
thermometer  should  be  placed  near  the  bed  of  the  patient,  and 
the  air  maintained  at  seventy  degrees,  Fahrenheit.  The  error  is 
often  committed  of  keeping  the  room  too  warm;  and,  when  the 
thermometer  denotes  more  than  seventy  degrees,  cool  air  must 
be  admitted  until  the  heat  is  reduced. 

The  patient  must  be  properly  cared  for,  and  this  duty  should 
be  committed  to  a  nurse,  if  possible,  who  has  had  experience  in 
such  work;  but  if  such  aid  cannot  be  had,  then  some  person  of 
self-possession  and  intelligence  must  be  instructed  by  the  surgeon 
in  the  duties  required.  The  most  important  task,  for  a  time,  is 
to  prevent  the  child  from  reaching  to  and  disturbing  the  canula. 
Through  lack  of  care  in  this  respect  the  writer  has  seen  the 
canula  nearly  plucked  out  from  the  trachea.  Hence,  for  an 
hour  or  two,  the  child's  hand  should  be  held,  or  prevented  from 
doing  mischief.  Another  task  quite  as  important  as  the  preceding 
is  to  watch  the  canula,  and  see  that  it  does  not  become  obstructed 
with  excreta  from  the  air-passage.  Such  material,  in  a  liquid  or 
semi-liquid  state,  in  coughing  is  continually  lodging  in  the 
canula;  and,  in  time,  it  becomes  inspissated  and  adherent  to  the 
inner  wall  of  the  canula.  To  prevent  such  accumulation,  the 
assistant  should,  occasionally,  pass  a  plumed  feather  into  the 
tube,  twirl  it  around,  and  thus  catch  and  extract  the  matter. 
For  this  purpose,  the  smaller  wing  feathers  of  the  domestic  fowl 
will  do  the  work  well.  This  is  pliant  enough  to  easily  traverse 
the  canula,  and,  being  turned  about,  it  will  dislodge  the  adherent 
matter.  In  using  this,  the  plumed  end  which  is  inserted  should 
be  carried  somewhat  beyond  the  lower  end  of  the  canula,  so  as 
to  entirely  detach  the  obstructing  matter.  In  the  beginning,  this 
will  irritate  the  mucous  membrane  and  provoke  coughing;  later; 
this  does  not  occur. 

Soon  after  the  work  is  completed,  and  breathing  through  the 
canula  is  freely  established,  the  patient  falls  asleep;  and  in  this, 
the  breathing  is  so  noiseless  that  the  inexperienced  watcher  fears 
that  something  is  wrong.  Besides  being  noiseless,  the  respiration 
may  be  slower  than  usual:  which  arises  from  the  canula  admit- 
ting more  than  the  normal  quantity  of  air. 

Visitors  and  useless  attendants  are  to  be  excluded  from  the 


tracheotomy;  beonchotomy.  1057 

patient's  room;  for  the  presence  of  such  will  render  the  air 
impure,  to  the  patient's  injury;  and  the  curious  and  inquisitive 
gaze  of  visitors  will  disturb,  if  not  alarm,  the  child.  The  presence 
of  the  parents  in  the  room,  unless  they  lose  their  self-possession, 
may  be  allowed 

To  arrest  the  pseudo-membranous  formation,  and  to  aid  in 
the  solution  of  that  which  may  be  present,  a  valuable  auxiliary 
is  to  atomize  some  agent  near  the  patient  which  has  such  solvent 
action.  For  this  purpose,  some  alkaline  agent  may  be  used  ;  as 
examples  of  such  are  lime  water,  or  a  solution  of  bicarbonate  of 
potash,  or  soda.  The  writer's  preference  is  for  lime  water,  of 
which  the  officinal  preparation  may  be  used  in  a  simple  atomiz- 
ing apparatus.  The  vapor  thus  generated  may  occasionally  be 
thrown  into  a  funnel  which  is  inserted  into  the  mouth  of  the 
canula.  Or  the  current  of  vapor  may  be  made  to  simply  play 
over  the  patient's  neck;  and  to  protect  the  dress  and  the  bedding 
from  moisture,  these  should  be  covered  with  India  rubber  cloth 
during  the  use  of  the  atomizer.  Another  agent  used  in  atomized 
state  that  has  enjoyed  some  celebrity,  is  chlorate  of  potash:  this 
may  be  used  in  saturated  solution,  viz.,  fifteen  grains  to  the  ounce 
of  water.  The  peroxide  of  hydrogen  may  also  be  used  in  atomized 
form. 

In  spite  of  all  the  care  used  in  cleansing  the  canula,  some 
material,  in  hardened  form,  will  collect  on  the  inside  of  the 
canula,  and  attenuate  its  calibre;  hence  the  inner  tube  must  be 
removed,  every  hour  or  two,  and  cleansed.  This  cleansing  will 
be  much  facilitated  if  a  solution  of  bicarbonate  of  potash  be 
employed  for  the  purpose.  In  the  act  of  removing  the  inner 
tube  and  replacing  it,  the  nurse,  if  untrained,  must  have  special 
instruction.  The  key,  which  attached  to  the  horizontal  plate 
fastens  the  inner  tube,  sometimes  works  ill.  If  the  retaining 
key  does  not  work  well  when  the  inner  tube  is  shifted,  the  child 
will  be  disturbed  and  probably  thrown  into  a  spasm  of  coughing: 
all  of  which  will  be  avoided  by  the  selection  of  the  canula  with- 
out such  defect. 

Trousseau  and  other  authorities  recommend  to  drop  occasion- 
ally, a  few  drops  of  warm  water  into  the  canula;  they  claim  that 
doing  this  one  compensates  for  the  absence  of  moisture  which 
arises  from  the  admission  of  air  through  the  canula;  instead  of 
through  the  nose  or  mouth.  The  use  of  an  atomizer,  in  the 
manner  before  referred  to,  renders  it  unnecessary  to  do  this,  since 
the  vapor  thus  generated  would  be  ample  to  moisten  the  air- 
passages. 


lOoS  rJIAUYNGEAL    AND    OESOPHAGEAL    NEOPLASMS. 

The  iuterual  medication  which  usually  has  been  plied 
assiduously,  and  often  to  excess,  may  be  reduced  to  a  minimum, 
or  discontinued,  when  tracheotomy  has  been  done:  but  the  nutri- 
tion of  the  patient  must  be  well  maintained. 

There  usually  occurs  at  once  a  great  amendment  in  the 
condition  of  the  patient;  and  both  parent  and  surgeon  indulge 
in  exaggerated  hope;  but  the  experienced  medical  man  tempers 
such  hope  with  prudent  reserve;  for  he  has  long  ago  learned  tliat 
apparently  assured  victory  may  end  in  defeat.  The  improvement 
is  too  often  merely  temporary;  the  slow  breathing,  within  a  few 
hours,  may  become  hastened;  the  pulse,  likewise,  accelerated; 
and  the  tranquil  composure  of  the  patient  may  be  exchanged  for 
one  of  restless  anxiety.  The  child  tosses  its  arms  about  and 
makes  the  same  appeals  for  help  which  it  did  before  the  operation. 
But  should  the  peaceful  composure  which  instantly  followed  the 
tracheotomy,  continue  into  the  second  day,  there  is  a  fair  prospect 
of  recovery. 

A  change  to  the  worse  is  announced  by  hastened  breathing, 
cpickened  pulse,  and  increase  of  temperature.  The  accelerated 
breathing  may  bo  caused  by  obstruction  of  the  trachea  below 
the  opening  into  it;  or  it  may  arise  from  pneumonic  cedema  or 
actual  inflammation.  The  conditions  of  the  lungs  supervening, 
a  fatal  ending  may  be  apprehended;  for  within  some  hours,  or  a 
day  or  two,  at  most,  the  pulmonar}'  breathing  space  becomes 
reduced  to  such  small  limits,  that  life  cannot  be  continued. 
Along  with  hastened  respiration,  the  air -passage  becomes  dry- 
but  little  material  collects  in  the  canula,  and  this  is  remarkably 
thick  and  adherent.  The  breathing  is  accompanied  by  a  creak- 
ing or  whistling  sound.  In  this  unfortunate  condition  the  writer 
has  seen  relief  from  the  frequent  use  of  the  atomized  lime  water; 
but  as  a  rule,  such  patients  die  in  the  latter  part  of  the  second 
day,  and  all  that  is  done  but  prolongs  the  scene  of  struggling 
agony. 

The  case  is  otherwise  where  the  unfavorable  condition  arises 
from  obstruction  of  the  trachea  through  an  accumulation  of 
inspissated  mucus  in  the  canal,  or  from  the  formation  of 
croupal  membrane  there;  in  such  patients  the  surgeon  can  often 
give  relief  by  extracting  the  impeding  material.  In  some  cases, 
though  the  false  membrane  be  thoroughly  removed  at  the  time 
of  the  operation,  yet  some  hours  afterwards  it  reforms,  and  the 
))atient  breathes  with  difficulty,  similar  to  that  which  necessitated 
the  0])eration.     In  such  condition,  the  canula  must  be  removed 


tracheotomy;  broxchotomy.  1059 

and,  the  lips  of  the  tracheal  wound  being  securely  grasped  and 
held,  a  pair  of  slender  forceps  is  to  be  introduced  into  the  trachea, 
and  the  material  caught  and  removed.  If  the  matter  be  thin, 
instead  of  forceps,  a  small  probang  may  be  passed  down  the 
trachea,  twirled  around,  and  the  passage  thus  freed  of  the 
obstructing  matter.  If  the  obstruction  arises  from  a  membra- 
nous formation  that  has  reappeared,  it  is  well,  after  the  removal, 
to  apply  some  solution  which  will  prevent  the  re-formation.  For 
this  purpose,  a  solution  of  corrosive  sublimate,  in  the  strength  of 
one  part  in  a  thousand,  may  be  used.  The  agent  whicli  the 
w^riter  has  found  most  effectual  is  nitrate  of  silver  applied  in 
solution,  of  which  the  strength  is  eight  grains  to  an  ounce  of 
distilled  water.  This  may  be  applied  with  a  small  probang, 
which,  being  passed  through  the  tracheal  opening,  is  caused  to 
ascend  and  descend  rapidly,  in  contact  with  the  tracheal  wall. 
The  surgeon  should  do  this  himself,  and  not  commit  the  work  to 
even  an  expert  nurse. 

Tlie  first  few  days  which  follow  the  operation  are  hours 
crowded  with  weighty  duty  for  the  surgeon;  at  short  intervals^ 
he,  or  his  representative  should  revisit  the  patient;  and  of  equal 
importance,  one  or  more  assistants  disciplined  in  such  work 
should  unremittingl}^  watch  the  case.  For  upon  the  faithful 
discharge  of  those  minor  duties,  as  well  remarks  Archambault, 
depend  the  chances  of  success,  rather  than  upon  perfection  in  the 
operation. 

At  the  end  of  forty-eight  hours,  if  all  has  proceeded  favorably, 
a  strong  hope  of  recovery  may  be  entertained;  and  the  conditions 
justifying  such  expectation  are  the  following:  the  pulse  is  under 
a  hundred,  the  temperature  does  not  exceed  one  hundred  and  a 
half,  or  one  hundred  and  one  degrees;  the  cough  is  absent  or 
slight,  and  the  air-passages  are  moist.  But,  as  before  mentioned, 
the  ominous  symptoms  are  constantly  accelerating  respiration  and 
disappearance  of  moisture  from  the  air-passages ;  the  supervention 
of  these  conditions  upon  the  previous  favorable  ones  almost 
certainly  portend  death  of  the  patient  w^ithin  twenty-four  or 
thirty-six  hours. 

The  child  which  has  been  operated  on  is  sometimes  disturbed 
by  finding  that  it  cannot  talk  as  hitherto;  though  its  tongue  and 
mouth  shape  words,  yet  not  even  a  whispering  sound  is  uttered: 
and  this  silence  renders  the  patient  anxious,  sad  and  dispirited: 
so  that  to  the  attendant  falls  the  further  task  of  amusing  the 
patient,  and  causing  him  to  forget  his  condition.     If  the  case  is 


lOGO  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

going  favorably,  the  child  may  soon  be  permitted  to  sit  up  in 
bed;  or  lie  may  be  lifted  ilom  bed  and  held  in  the  arms  of  the 
nurse.  The  tractable  or  intractable  character  of  the  child  will 
determine  how  this  management  must  be  pursued. 

The  precautions  given  in  regard  to  maintaining  the  room  at 
a  uniform  temperature  are  of  much  importance;  and  besides  this, 
should  albumen  be  found  in  the  urine,  the  child  must  be  well 
clothed  both  during  the  time  that  the  canula  is  used,  and  also 
after  the  removal. 

In  feeding  the  patient,  care  must  be  used  that  no  foreign 
matter  enter  the  canula:  and  though  the  nutrient  material  be 
liquid,  its  entrance  into  the  air-passage  would  prove  extremely 
detrimental.  Such  accident  occurs  oftenest  when  the  child  takes 
too  large  a  draught,  and  a  portion  escaping  from  the  mouth 
overflows  on  the  neck  and  enters  the  wound.  More  care  in  giving 
food  will  avoid  this  accident. 

After  the  lapse  of  a  few  days  of  anxious  solicitude  and  weighty 
suspense,  the  fortunate  patient  is  rescued  from  most  of  the  perils 
which  menaced  him:  yet  one  more  eventful  period  must  be  passed ; 
and  this  is  that  in  which  the  canula  must  be  removed.  The 
child,  which,  at  first,  was  alarmed  by  the  new  mouth-piece  to  the 
air-passage,  soon  learns  to  tolerate  it,  and  finally  fears  to  part 
with  it;  and  a  similar  fear  often  harasses  the  surgeon:  his 
uncertainty  voices  itself  in  the  famous  words,  "If  it  were  done 
when  'tis  done;"  and  if  he  has  had  little  experience  in  such  cases, 
he  is  embarrassed  by  hesitation  in  the  selection  of  the  proper  hour 
for  this  work. 

The  canula  can  onl}^  be  removed  when  the  calibre  of  the 
superjacent  air-passage  is  fully  restored :  and  in  case  the  instru- 
ment be  taken  out  before  this  restoration,  the  expectation  that  the 
wound  will  freely  admit  air  is  seldom  realized.  It  often  occurs 
that,  the  canula  being  withdrawn,  the  altered  condition  alarms 
the  child,  and  causes  it  to  struggle  and  breathe  violently,  the 
result  of  which  is  that  the  lips  of  the  tracheal  wound  close  and 
allow  but  little  air  to  enter;  and  in  such  condition,  the  writer 
has  seen  the  patient  almost  lost  by  asphyxia.  The  violent 
struggling  movements  of  the  child  render  it  extremely  difficult 
to  reinsert  the  canula;  and  this  can  only  be  done  by  the  aid  of  a 
couple  of  assistants.  In  such  emergency,  dispensing  with  tenac- 
ulum or  retractor,  the  writer  has  used  a  pair  of  dressing  forceps, 
of  which  the  closed  blades  being  introduced,  the  instrument  is 
then  opened  and  the  wound  dilated  so  that  air  can  enter,  and  the 
canula  be  replaced. 


tracheotomy;   bronchotomy.  1061 

The  modern  canula  is  so  constructed  that  the  suro;eon  can 
determine  before  its  abstraction  whether  its  absence  can  be  borne: 
this  consists  in  an  opening  in  tlie  outer  tube  at  a  point  where 
the  expired  air  can  pass  upwards  through  the  natural  route, 
when  the  outer  mouth  of  the  tube  is  closed.  To  test  the  permea- 
bility and  patency  of  the  larynx,  let  the  inner  tube  be  withdrawn  ; 
and  when  the  patient's  attention  is  withdrawn,  place  the  finger 
over  the  mouth  of  the  outer  tube  and  thus  test  the  degree  of 
permeability  of  the  larynx:  and  if  the  breathing  be  free,  then  a 
more  prolonged  test  of  this  can  be  made  by  closing  the  canula 
with  a  cork.  If  such  closure  be  tolerated  for  some  time,  then  the 
canula  may  be  withdrawn;  and  if  all  has  proceeded  favorably 
from  the  time  of  the  operation,  then  removal  can  sometimes  be 
done  as  early  as  the  fifth  day:  but  usually,  this  cannot  be  done 
before  the  ninth  or  tenth  day. 

After  the  canula  is  removed,  some  authorities  permit  the 
wound  to  remain  wdth  little  or  no  dressing:  others,  on  the  con- 
trary, approximate  the  lips  of  the  opening  with  adhesive  plaster. 
For  this  purpose,  the  author  uses  isinglass  plaster,  of  which 
strips  six  inches  long  and  a  half  inch  wide  may  be  so  stretched 
across  the  opening  as  to  approximate  the  sides.  For  some  hours 
after  such  closure,  the  air  in  inspiration  and  expiration  wall  pass 
through  the  interstices  of  the  plaster:  and  this  may  continue  for 
some  days,  before  the  w'ound  is  so  closed  as  to  prevent  the  passage 
of  air.  Ordinarily,  the  wound  heals  without  delay:  exceptionally, 
this  does  not  occur;  especially  in  the  subjects  of  severe  diphthe- 
ritic disease. 

The  most  frequent  embarrassment,  which  tlie  operator 
encounters  after  the  removal  of  the  canula,  is  an  excessive  gran- 
ulative  growth  which  develops  in  the  wound;  and  such,  growth 
often  so  encroaches  on  the  tracheal  canal  that  respiration  is 
interfered  with.  This  occurred  in  two  cases  of  tracheotomy  done 
by  the  writer,  and  amounted  to  a  formidable  obstacle  to  recovery. 
In  the  first  patient,  the  canula  was  removed  on  the  tenth  day, 
and  for  two  or  three  days  the  case  proceeded  favorably,  and  an 
early  recovery  seemed  probable :  but  as  the  wound  was  near  the 
point  of  final  closure,  the  breathing  became  difficult,  and  in  a  few 
hours  the  dyspnoea  reached  such  a  gravity  that  it  became 
necessary  to  reopen  the  trachea  and  introduce  the  canula  again. 
In  this  work  it  was  found  that  thegranulative  tissue  had  reached 
inwards,  and,  in  polypoid  form,  nearly  occluded  the  tracheal 
canal.     This  neoplasm  was  excised,  and  the  deeper  portion  of  the 


1062  I'HAKYMiKAL    AND    CESOPIIAGKAL    NEOl'LASMS. 

wouiul  cauterized  with  nitrate  of  silver.  After  a  few  days,  the 
canuhi  was  again  removed,  when  similar  difficulty  in  respiration 
recurred.  It  M'as  treated  similarly,  with  the  same  result  as 
occurred  the  first  time.  The  procedure  next  attempted  was  to 
trim  olT  all  the  raw  surface,  and  convert  the  old  wound  into  a 
new  one,  in  which  the  walls  were  fresh  wounds:  then  the  incision 
was  carried  downwards,  and  the  canula  having  been  inserted  in 
this  lower  point,  the  upper  portion  of  the  wound  was  closed  by 
deep  suture.  Thus  the  old  wound  quickly  healed,  after  which 
the  canula  was  removed  from  the  new  one,  which,  also,  healed. 
In  this  way  perseveringly  pursued,  through  difficulties  which 
have  been  but  half  recounted,  the  patient  was  finally  cured:  and 
but  a  tithe  of  the  service  paid  for,  since  the  parent  held  the 
operation  responsible  for  the  later  difficulties  which  were  encoun- 
tered: as  logical  as  are  many  of  the  ingrates  for  whom  Medicine 
saves  life.  In  the  patient  here  mentioned,  after  recovery,  respira- 
tion was  untrannneled. 

In  another  patient,  still  greater  trouble  was  encountered  in 
dispensing  with  the  canula:  after  the  removal  of  the  latter  the 
trachea  soon  became  obstructed  by  graniflative  tissue,  and  it  was 
necessary  to  reopen  the  wound,  and  replace  the  canula;  yet 
before  doing  so,  the  new  tissue  was  thoroughly  excised.  After 
the  second  removal  of  the  canula,  the  granulative  growth  soon 
reappeared:  and  this  time,  instead  of  removal  by  excision,  it  was 
done  by  cauterization  with  the  small  blade  of  the  thermal  cautery. 
This  cauterization  was  done  a  second,  and  even  a  third  time, 
before  the  exuberant  growth  was  so  repressed  as  to  admit  of 
closure  of  the  tracheal  wound.  This  child  recovered,  yet  the 
tracheal  canal  was  left  in  an  imperfect  condition.  When  the 
boy  was  at  rest,  and  breathing  was  not  accelerated,  there  was  no 
embarrassment;  yet  when  active  exercise  induced  a  greater 
demand  for  air,  then  the  respiration  was  labored;  and  it  was 
evident  that  there  was  stenosis  of  the  trachea  at  the  point  where 
it  had  been  opened.  This  lad  has  now  reached  manhood,  and 
though  his  respiratory  difficulty  has  lessened,  yet  enough  of  it 
remains  to  seriously  disturb  him  when  he  engages  in  active 
exercise. 

In  a  third  patient  there  was  encountered  similar  difficult}^ 
yet  there  was  less  trouble  in  repressing  the  granulative  growth 
and  dispensing  with  the  use  of  the  canula:  the  work  was  here 
done  with  the  thermal  cautery. 

From  the  writer's  observation  he  concludes  that  tlie  prolific 


tracheotomy;  bronchotomy.  1003 

granulative  growth  arises  from  retaining  the  canula  too  long  in 
place:  for  it  did  not  appear  in  patients  in  whom  the  instrument 
had  been  removed  early;  and  it  only  occurred  in  those  in  whom 
the  canula  had  been  used  for  ten  days,  or  longer.  Hence,  in 
practice  may  be  formulated  the  rule  to  remove  the  canula  as 
soon  as  the  air-passage  above  is  sufficiently  permeable  to  permit 
free  breathing;  and  this  can  often  be  done  as  early  as  the  fifth 
day  after  the  operation. 

A  singular  difficulty  sometimes  met  is  that  the  child  having 
breathed  for  a  few  days  through  the  canula  forgets  the  habit  of 
breathing  through  the  nose  or  mouth;  or  does  so  with  distrust; 
and  such  a  patient,  after  the  extraction  of  the  canula,  from  slight 
causes  may  have  a  panic  of  dyspnoea,  in  which  it  quite  loses  its 
breath,  and  life  is  so  imperiled  that  it  becomes  necessary  to 
replace  the  canula.  Such  trouble  was  experienced  in  a  case 
operated  on  by  the  writer.  This  child  was  cajoled  into  natural 
breathing  by  removing  the  inner  canula,  and  then  when  the  child 
fell  asleep,  the  remaining  canula  was  closed  by  a  cork,  and 
allowed  to  remain  so  after  the  child  awoke;  breathing  then 
occurred  normally  through  the  fenestra  of  the  remaining  tube. 
By  this  management  the  child  was  finally  trained  to  breathe 
without  the  aid  of  tlie  canula. 

Instead  of  excessive  growth  from  the  wounded  tissues,  there 
may  be  a  defect  in  their  reparative  action;  and  sometimes  there 
is  an  "ulcerative  action,  by  which  the  wound  is  increased  in 
dimensions.  In  such  a  case  there  is  encountered  no  dyspnoeic 
difficulty,  since  there  is  ample  ingress  of  air  tlirough  the  wound, 
as  well  as  through  the  laryngeal  canal:  but  there  is  trouble  in 
effecting  closure  of  the  wound.  Such  ulcerative  action,  or  indo- 
lence in  the  work  of  repair,  may  arise  from  mal-nutrition  of  the 
subject,  which  previously  existed,  or  may  be  caused  by  the  diph- 
theritic disease  which  led  to  the  operation.  Such  patient  should 
be  fed  as  generously  as  the  digestive  powers  will  permit,  and  to 
awaken  appetite,  there  may  be  given  three  times  daily  a  wine- 
glassful  of  decoction  of  bark  or  gentian,  which  has  recently  been 
made,  and  acidulated  with  hydrochloric  acid.  As  a  local  stimu- 
lant, the  surface  of  the  wound  may  daily  be  touched  with  a 
solution  of  nitrate  of  silver,  viz.,  one  grain  to  the  ounce  of  distilled 
water;  or  with  a  ten  per  cent  solution  of  alcohol.  Exercise  in 
the  open  air  and  sunshine  will  act  favorably:  yet  a  portion  of 
the  time,  the  patient  should  be  in  a  recumbent  position,  in  which 
the  afflux  of  blood  to  tlie  part  will  be  promoted.     And  to  retard 


10G4  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

and  hold  tlio  blood  in  the  tissues  about  the  wound,  the  neck  may 
be  encircled  with  two  strips  of  adhesive  plaster  placed  horizon- 
tally, and  so  situated  as  to  include  the  wound  between  them. 
Instead  of  adhesive  plaster  collodion  may  be  used. 

In  some  unfortunate  cases,  owing  to  some  constitutional 
cachexy,  or  to  depression  of  the  vital  forces  through  the  virulence 
of  the  diphtheritic  poison,  the  wound  becomes  the  site  of  pro- 
gressive gangrene:  instead  of  healing,  the  parts  die;  and  in  such 
cases  the  death  of  the  patient,  as  a  rule,  soon  afterwards  follows. 
To  ujdift  the  enfeebled  vital  forces,  the  chief  reliance  should  be 
placed  in  concentrated  nutrition  and  a  free  use  of  stimulants; 
and  as  local  treatment,  a  cataplasm  composed  of  powdered  char- 
coal and  pulverized  Peruvian  bark  moistened  with  red  wine  may 
be  used.  And  to  combat  the  probable  microphytic  causal  agency, 
the  surface  of  the  wound  may  be  penciled  dailj''  with  Oleum 
Terebinthinse.  Such  a  course  of  treatment  should  be  diligently 
carried  out:  more  in  the  line  of  duty  than  with  the  expectation 
of  saving  the  patient. 

A  grave  intercurrence  which  sometimes  appears  in  the  subject 
of  tracheotomy,  is  pais}'  of  the  muscles  of  the  pharynx  and 
throat,  which  are  concerned  in  the  function  of  deglutition.  This 
ill  event  is  referable  to  alterations  in  the  nerves  which  fui'nish 
motor  and  sensory  influence  to  these  structures :  such  nerves  are 
the  glo.sso-pharyngeal,  and  branches  of  the  pneumogastric  dis- 
tributed to  the  pharynx  and  larynx.  It  is  probable  that  the  cell- 
growth  which  accompanies  the  diphtheritic  process  penetrates 
and  trammels  the  ofRce  of  these  nerves:  that  such  infiltration 
does  occur  the  pathologist  has  verified:  it  was  inferable  from 
the  macroscopic  appearances  of  the  structures  in  necropsies  made 
by  Virchow  and  Bouchut,  wliich  were  witnessed  by  the  writer. 
That  the  disease  traveled  centrally  from  the  throat  along  the 
nerve  sheaths  to  the  medulla  oblongata,  and  there  exercised  its 
paralyzing  action,  is  problematical,  though  Bouchut  endeavored 
to  show  this  in  his  demonstration  made  at  the  Hospital  des 
Enfants,  Paris.  The  morbid  action  is  exerted,  probably,  chiefly 
or  wholly,  on  the  terminal  ramuscules  of  the  nerves  supplying 
the  })alsied  parts. 

As  results  of  such  loss  of  innervation  are  the  loss  of  voice,  and 
difficulty  of  swallowing.  The  voice  is  first  reduced  to  a  whisper, 
and  this  soon  disappears:  and  then  the  effort  to  talk  is  reduced 
to  mimic  movements  of  the  tongue  and  lips,  similar  to  those 
made  b}'  the  patient  when  aphonia  arises  from  the  trachea  being 


tracheotomy;  bronchotomy.  1065 

occupied  b}^  the  canula:  the  muscular  movements  are  made 
which  should  coin  the  voice  into  articulated  sounds,  yet  the  voice 
for  coinage  is  absent.  The  graver  trouble  is  the  inability  to 
swallow :  at  first,  the  component  acts  of  deglutition  are  wrongly 
coordinated;  and  strangling  occurs;  and  finally,  a  portion  of  the 
liquid  food,  instead  of  taking  the  normal  route,  enters  the  larynx 
and  descends  to  the  lungs;  so  that  the  child  has  a  violent  fit  of 
coughing  every  time  it  attempts  to  swallow  liquid  nutriment.' 
The  result  of  this  is  that  the  patient  is  but  partly  nourished,  and 
the  lungs  receiving  foreign  matter,  soon  become  affected  with 
ichorous  pneumonia.  The  harassing  cough  which  is  aroused  by 
swallowing  finally  causes  the  child  to  refuse  food. 

As  treatment  which  has  proved  most  beneficial  in  such  case 
is  electricity  and  strychnia.  Potain  has  reported  a  case  in  which 
electricity  speedily  overcame  the  palsy.  Also,  Dr.  Colin,  of  San 
Francisco,  has  had  excellent  results  from  the  administration  of 
strychnia :  even  where  the  palsy  was  general  and  not  limited  to 
the  throat.  The  writer  has  found  that  it  is  better  to  give  food  in 
solid,  rather  than  in  liquid  form :  bread  can  be  swallowed,  when 
milk  would  cause  strangling.  And  as  an  important  adjuvant, 
rectal  nutrition  should  be  resorted  to;  and  for  this,  no  article  of 
aliment  is  equal  to  milk ;  and  the  absorption  of  this  will  be  aided 
by  the  addition  of  the  extract  from  the  salivary  glands  and  the 
pancreas  of  the  ox,  hog  and  sheep.  ^ 

A  complication  sometimes  arising  from  tracheotomy  is  sup- 
puration in  the  wound,  from  which  pus  gravitates  downwards, 
and  may  enter  the  anterior  mediastinal  space  of  the  thorax. 
This  results  from  unskilled  work  in  operating,  in  which  the 
structures  are  needlessly  lacerated  and  separated  from  each  other, 
so  that  blood  and  excreta  from  the  wound,  instead  of  escaping, 
enter  and  gravitate  downwards.  Also,  from  awkward  insertion 
of  the  canula,  the  structures  may  be  forcibly  dissected  from  the 
trachea,  and  thus  a  route  is  opened  into  which  the  materials 
mentioned  may  enter  and  descend.  This  pus  lodged  behind 
the  sternum  is  concealed  from  sight,  and  is  onl}^  revealed  by  a 
necropsy ;  and  as  such  examination  is  often  not  made,  the  exist- 
ence of  the  pus  is  not  suspected,  though  it  was  a  material  factor 
in  causing  death.  If,  however,  it  be  detected,  an  attempt  to 
remove  it  should  be  made  by  partially  inverting  the  patient,  as 
often  as  every  six  hours,  and  washing  out  the  cavity  with  alco- 
holized water :  thus  diligently  working,  the  purulent  cavity  might 
finally  be  closed.  And  should  pus  originating  from  any  other 
68 


lOGG  PHARYNGEAL    AND    CESOPHAGEAL    NEOPLASMS. 

cause  during  tlie  course  of  tracheotomy,  for  example,  from  ery- 
sipelas or  phlegmonous  inflammation,  enter  the  thorax,  thena 
similar  treatment  might  be  pursued.  Such  work  falls  rather 
within  the  line  of  hopeless  action,  id  alt  quid  feci  sse  vichamur. 

A  complication  sometimes  disturbing  the  course  of  a  trache- 
otomy is  ulceration  of  the  trachea.  This  may  arise  from  pressure 
of  the  canula,  and  may  occur  in  the  margins  of  the  tracheal 
incision,  or  where  the  convexity  of  the  tube  rests  against  the  pos- 
terior wall  of  the  trachea;  or  it  may  be  lower  down,  where  the 
end  of  the  canula  rests  on  the  .tracheal  wall.  It  has  been  seen 
oftenest  in  the  lower  part  of  the  tracheal  cut.  This  ulcerative 
action  may  be  very  superficial,  or  it  may  reach  quite  through  the 
thickness  of  the  wall.  And  cases  have  been  recorded  in  which 
the  perforation  reached  and  opened  the  wall  of  a  vessel,  and  seri- 
ous or  fatal  bleeding  occurred. 

Such  ulceration  is  partly  due  to  the  pressure  of  the  canula;  it 
is  likewise  promoted  by  the  erosiveaction  of  the  instrument,  which 
is  kept  in  constantmotion  by  the  respiratory  movements :  and  such 
agency,  whether  pressure  or  erosive  friction,  will  have  greater 
effect  when  reinforced  by  infectious  diphtheritic  disease.  And  if 
such  disease  be  of  a  virulent  character,  then  there  may  occur 
extensive  gangrenous  destruction  of  the  walls  of  the  trachea. 

The  pain  from  such  ulcerative  or  gangrenous  action,  though 
present,  is  liardly  distinguishable  from  that  caused  by  the  con- 
tiguous wound:  and  lience  it  is  of  little  diagnostic  value;  the 
diagnosis  is  to  be  made  rather  by  the  dark  discoloration  of  the 
canula,  provided  this  be  of  silver.  The  silver  tube  becomes 
blackened  through  the  formation  of  the  sulphuret  of  silver,  which 
is  due  to  the  contact  of  the  tube  with  the  disintegrated  cartilage, 
which  contains  sulphur.  And  the  location  of  this  black  stain 
will  indicate  the  point  where  the  tube  caused  pressure:  namel}', 
if  it  be  at  the  lower  end  of  the  canula,  it  can  be  inferred  that 
pressure  there  is  causing  ulcerative  chondritis;  or  if  the  posterior 
convex  curve  be  blackened,  this  denotes  disintegration  at  that 
part  of  the  trachea;  or  should  the  entire  canula  be  blackened, 
then  the  inner  surface  of  the  trachea,  wherever  it  touches  the 
canula,  is  breaking  down  from  mechanical  cause,  or  from  di})h- 
theritic  infection.  But  should  the  upper  end  of  the  canula  and 
the  horizontal  plate  be  darkened,  this  may  proceed  from  the  pus 
of  the  wound,  and,  meantime,  the  trachea  be  intact. 

In  case  the  canula  be  of  material  which  can  form  no  colored 
compound  with  sulphur,  then  the  diagnostic  aid  of  discoloration 
would  be  wantincr. 


tracheotomy;  bronxhotomy.  1067 

As  means  of  treatment,  the  following  may  be  resorted  to :  if 
the  ulceration  wholly  arises  from  erosive  action  of  the  canula, 
this  may  be  remedied  by  the  use  of  an  instrument  of  a  different 
size,  or  model.  To  lessen  or  avoid  erosive  attrition,  a  canula  has 
been  constructed  by  Luer,  under  the  direction  of  Roger,  of  which 
the  tubular  section  is  movable  within  the  horizontal  portion.  Bv 
this  device  the  horizontal  plate  is  not  disturbed  by  the  movement 
of  the  head  and  neck;  and  the  unfixed  or  movable  canula  can 
cause  but  little  attrition  during  the  respiratory  movements. 

But  in  the  event  that  the  ulceration  or  gangrene  is  produced 
by  diphtheritic  infection,  it  must  be  combated  by  some  topical 
remedy;  and  for  this  purpose  pure  alcohol  or  the  spirit  of  turpen- 
tine may  be  applied  to  the  affected  part. 

The  writer  will  here  briefly  refer  to  his  own  experience  in 
tracheotomy.  He  has  operated  sixty  times,  and  has  saved 
twelve  cases;  that  is,  twenty  per  cent.  The  cases  were  children 
suffering  with  croup  or  diphtheria,  and  at  ages  varying  from 
two  and  a  half  to  seven  years  of  age.  In  many  of  the  patients 
the  operation  was  only  permitted  when  the  child  was  in  a  hope- 
less condition:  and  so  near  death  were  a  few  of  the  children  that 
they  died  during  the  operation:  in  these,  and  in  others,  had  the 
operation  been  done  earlier,  the  writer  is  convinced  that  one- 
third  of  the  patients  would  have  been  rescued.  The  section 
■was  always  the  high  one  in  which  the  cricoid  cartilage  was 
sometimes  included.  Other  facts  concerning  these  operations 
have  already  been  referred  to. 

In  the  foregoing  collection  of  facts,  it  has  been  the  purpose  of 
the  author  to  furnish  the  reader  with  a  full  store  of  materials 
which  may  serve  for  guidance  in  the  critical  work  of  tracheotomy. 
As  before  stated,  the  operation  may  be  one  of  the  simplest  char- 
acter: a  few  strokes  of  the  scalpel  then  suffice  to  open  the  tracheal 
fenestra.  But  exceptionally,  this  narrow  field  may  be  the  lurk- 
ing place  of  uncounted  difficulties;  so  that  though  the  operator 
may  have  in  his  mind  an  ample  store  of  shifts  and  expedients, 
still  chance  may  summon  up,  anon,  some  contingency  which  he 
did  not  expect;  but  with  wdiich  it  is  believed  the  preceding  expo- 
sition of  facts  will  enable  him  tD  satisfactorily  cope. 

No  moment  in  the  surgeon's  life  can  be  happier  than  the  one 
in  which  he  saves  a  life.  And  if  life  be  valued  by  its  number  of 
3^ears,  upon  no  one's  work  can  a  higher  estimate  be  placed  than 
on  that  of  the  tracheotomist:  for  he  rescues  from  death  the  young. 
And  should  the  operator  fail  to  save  his  patient,  as  he  often  does. 


10G8  PHARYNGEAr.    AND    (ESOrHAGEAL    JS'EOPLASMS. 

yet  lie  lias  tlie  satisfaction  of  knowing  that  he  has  not  shortened 
life;  and,  further,  that,  though  death  won  the  victim,  yet. the 
former  was  robbed  of  its  terror:  for  tracheotomy  assures  a  pain- 
less death, — enthanasia,  or  happy  death,  as  the  Greek  beautifully 
expresses  it. 

As  concluding  advice  to  tlie  tracheotomist,  the  latter  must 
bear  in  mind  that  his  task  to  end  well  must  be  one  of  tireless 
care  and  constant  attention  to  minute  details:  for  here,  as  else- 
where, the  crown  of  success  awaits  him  who  best  toils  and  best 
watches. 


CHAPTER  XXXII. 


LARYNGOTOMY. 


A  SUBJECT  cognate  to  tracheotomy  is  laryngotomy,  which  will 
next  be  considered.  As  tracheotomy  is  yielding  a  portion  of  its 
work  to  the  intubationist,  so  that  of  laryngotomy  is  being  some- 
what supplanted  by  the  procedures  of  the  laryngoscopist:  and,  as 
usual,  the  old  method  has  not  willingly  borne  the  encroachment 
of  the  new;  so  that  the  laryngotomist  and  the  laryngoscopist  at 
the  present  hour  are  vigorously  wielding  the  foils  of  heated  con- 
troversy; and  in  listening  to  the  dialectics  of  the  respective 
claimants  the  observant  reader  is  both  diverted  and  instructed, 
and  is  convinced  that  each,  with  some  selective  care,  may  be 
followed. 

In  laryngotomy,  the  entire  larynx  may  be  opened;  yet  it  is 
rare  that  such  an  extensive  operation  is  demanded:  usually 
the  opening  is  made  through  the  cricoid  cartilage,  the  crico- 
thyroidean  ligament,  the  thyroid  cartilage,  or  through  the  thyro- 
hyoidean  ligament.  AVhen  a  vertical  section  is  made  through  all 
the  component  parts  of  the  larynx,  the  work  is  named  total 
laryngotomy;  and  it  may  be  remarked  that  the  indications  for 
such  an  extensive  operation  will  seldom  present  themselves; 
usually,  the  purpose  for  which  the  operation  is  performed  can  be 
accomplished  by  an  opening  througli  one  of  tlie  component  parts 
of  the  larynx:  and  when  it  is  desired  to  do  this,  the  incision  may 
be  made  through  the  ligament  above  or  below  the  thyroid  car- 
tilage. The  operation  generally  designated  by  laryngotomy  is 
that  in  which  the  thyroid  cartilage  is  partly  or  wholly  divided: 
yet  the  term  thyreotomy,  by  which  this  operation  is  often  desig- 
nated, is  the  more  appropriate  name.  An  operation  cognate  to 
the  one  just  named  is  that  in  which  a  passage  is  made  through 
the  lateral  or  anterior  face  of  the  larynx,  by  exsecting  a  portion 
of  the  thyroid  cartilage. 

The  operation  of  laryngotomy  is  an  old  one;  it  is  mentioned 
by   writers  of  the  seventeenth  century;    and  in  the  eighteenth 

( 1069 ) 


1070  LARYNGOTOMY. 

ceiiuuy  it  is  mentioned  by  Detluirdini;-,  of  Rostock;  also  by  Vic 
d'Azyr  and  Sabatier  in  France.  The  operation  referred  to  by 
these  writers  was  that  in  which  an  opening  was  made  into  the " 
larynx  through  the  crico-thyroidean  space.  The  authority  who 
merits  special  credit  for  the  advocacy  of  laryngotoniy  in  the 
eighteenth  century  was  Desault,  whose  intelligent  hand  also 
advanced  other  sections  of  surgery.  One  finds  in  the  first  half 
of  the  present  century  the  records  of  a  number  of  cases  of  laryn- 
gotoniy: the  operators  were  German,  French  and  Fnglish  ;  and 
the  work  was  chiefly  done  for  the  removal  of  foreign  bodies 
which  had  entered  and  lodged  in  the  larynx,  usually,  in  tlie 
ventricle  of  Morgagni.  Thus  needles  and  the  seeds  of  cherries 
and  plums,  were  extracted. 

The  first  operation  of  thyreotomy  recorded  was  performed  by 
Brauers,  who  opened  the  cartilage  for  the  removal  of  an  intra- 
laryngoal  growth;  tlie  patient  recovered  and  lived  twenty  years 
afterwards. 

Laryngotomy  was  done  by  Larrey  in  his  experience  as  mili- 
tary surgeon,  for  relief  in  gunshot  wounds  of  the  larynx:  he 
operated  but  a  few  times,  and  on  the  whole  with  doubtful  result. 
The  operation  was  done  twice  by  G.  Buck,  of  New  York. 

Laryngotomy  has  been  done  for  the  following  purposes:  for 
tlie  removal  of  foreign  bodies  which  have  lodged  in  the  larynx, 
as  aid  in  certain  injuries  of  the  i)art,  for  relief  of  laryngeal 
stricture,  and  to,prepare  a  way  for  the  removal  of  intra-laryngeal 
growths. 

As  before  mentioned,  wliether  the  relief  for  the  exigencies 
enumerated  may  best  be  done  by  a  route  incised  througli  the 
laryngeal  wall;  or  whether  the  way  proposed  by  nature  is  the 
better  one,  is  an  unended  contest  between  the  surgeon  with  his 
scalpel,  and  the  laryngoscopist;  with  his  mirror  and  forceps,  the 
latter  justly  occupies  the  greater  part  of  tlie  field,  yet  the  general 
surgeon  holds  a  portion  of  it,  and  will  continue  to  do  so:  and 
when  the  controversy  is  ended,  the  two  should  occupy  this 
ground  in  common,  and  remain  mutual  allies  of  each  other. 

The  most  ordinary  object  for  which  laryngotomy,  for  a  long 
time,  was  performed,  was  the  removal  of  some  body  lodged  in 
the  larynx.  As  a  preliminary  aid  in  this  case,  to  get  immediate 
relief  for  the  pressing  demand  for  breath,  tracheotomy  should  be 
done;  and  even  though  the  dyspnoeic  symptoms  are  not  great,  it 
is  well  to  first  open  the  trachea,  and  introduce  a  canula;  for  thus 
doing,  the  surgeon  forestalls  the  possible  emergency  in  which 


LARYNGOTOMY.  1071 

the  shifting  of  the  foreign  body  may  induce  a  fit  of  strangling,  or 
fatal  suffocation. 

Also,  through  the  tracheal  opening  it  is  sometimes  possible 
to  pass  an  instrument  upwards  into  the  larynx  and  dislodge  the 
body;  and  for  this  a  convenient  instrument  is  a  soft,  flexible 
sound:  the  urethral  sound  of  India  rubber  or  gutta  percha  may 
be  emplo3^ed.  In  this  manner  the  writer  removed  by  the  aid  of 
tracheotomy  a  large  metallic  body  that  had  lodged  in  the  larynx, 
by  forcing  it  upwards.  As  soon  as  the  object  was  expelled,  the 
breathing  was  easy,  and  there  being  no  need  of  a  canula,  it 
was  dispensed  with,  and  the  wound  closed  by  sutures. 

Should  the  attempt  prove  fruitless  to  thus  force  the  body 
upwards,  or  to  extract  it  through  the  tracheal  opening,  then  let 
the  tracheal  wound  be  maintained  patent  by  means  of  a  pair  of 
dressing  forceps,  passed  inwards  and  downwards,  and  then 
opened ;  then  having  lowered  the  patient's  head,  introduce  the 
nozzle  of  a  syringe  and  throw  a  stream  of  water  through  the 
larynx.  If  the  head  be  well  dependent,  such  a  stream  of  water 
will  flow  towards  the  pharynx  and  escape  through  the  mouth  or 
the  nostrils:  the  same  as  blood  does  in  operations  done  in  the 
Rose  position;  that  is,  wdth  the  trunk  raised  and  the  head 
lowered.  In  this  way  it  is  probable  that  a  body  which  is  lodged 
in  the  larynx  would  be  carried  by  the  water  into  the  oral  cavity. 
If  the  object  be  sharp-pointed,  as  a  needle  or  a  fish-bone,  and 
have  become  fixed  by  insinuating  its  point  into  the  mucous 
membrane,  even  then  such  a  stream  of  water  might  dislodge  and 
carry  away  the  object.  And  as  this  hydraulic  washing  would  be 
harmless,  it  should  be  tried  before  the  more  formidable  procedure 
of  laryngotomy  is  resorted  to.  Another  method  akin  to  irrigation 
would  be  to  attach  a  piece  of  sponge  to  a  thread  and  carry  the 
thread  by  means  of  a  flexible  tube  through  the  w^ound  upwards 
through  the  larynx  into  the  mouth ;  then  by  traction  on  the 
cord,  the  sponge  could  be  drawn  through  the  larynx;  and  in  its 
passage,  it  would  probably  sweep  out  any  object  lodged  in  the 
canal.  And  finally,  should  these  non-operative  plans  fail,  then 
a  resort  to  thyreotomy  would  be  permissible. 

Thyreotomy,  done  for  the   removal   of  foreign  bodies,  has 
generally  proved  a  successful  operation.     Durham  has  collected  . 
a  list  of  twelve  cases,  done  for  this  purpose,  which   terminated 
successfully;  and  in  most  of  the  patients  the  work  done  did  not 
injure  the  voice. 

In  case  of  wounds  of  the  larynx  from  gunshot  or  other  causes. 


1072  LAKYXGOTOMY, 

laryngotomy  may  become  necessary:  but  here,  to  insure  a  free 
route  for  breathing,  tracheotomy  should  first  be  done,  and  a 
canula  inserted.  After  this,  the  surgeon  may  leisurely  {jrocecd 
to  treat  the  laryngeal  wound,  in  which  one  of  the  main  objects 
is  to  replace  dislocated  fragments.  Sometimes,  the  restitution  to 
form  can  be  done  througli  the  wound:  and  this  may  be  enlarged 
if  the  opening  be  too  small  for  the  introduction  of  probe,  forceps, 
or  other  instrument  needed  in  the  rectification  of  the  fragments. 
Where  the  wound  cannot  be  thus  utilized,  then,  as  Eichenmann 
has  done,  an  incision  may  be  made  through  the  crico-thyroid 
ligament  and  the  lower  part  of  the  thyroid  cartilage;  and  thus 
reposition  of  fragments  can  be  effected.  For  retention  of  the 
fragments  in  proper  site,  a  T-shaped  canula  may  be  used:  and 
this  is  to  be  constructed  of  two  rectangular  sections  of  which 
each  can  be  introduced  separately,  and  when  united,  a  canula  is 
formed  of  tliem,  of  which  one  portion  lies  vertical,  reaching 
above  and  below  the  laryngeal  wound,  while  the  horizontal  part 
traverses  and  reaches  beyond  the  laryngeal  wall.  One  part  of 
this  ingeniously  contrived  instrument  can  be  removed,  while  the 
other  remains  in  site.  This  instrument  must  be  maintained  in 
its  place  for  a  number  of  weeks,  until  the  injured  larynx  has 
healed :  for  if  it  be  removed  prior  to  healing,  then  cicatricial 
contraction  can  occur  and  interfere  with  voice  and  respiration. 

Injury  of  tlie  interior  of  the  larynx  from  the  entrance  of 
caustic  liquids,  as  acids,  or  alkalies,  as  well  as  from  boiling  water, 
according  to  Durham,  becomes  an  indication  for  thyreotomy. 
The  laryngoscopist  would  claim  that  these  cases  lie  within  his 
domain :  and  always  in  the  adult  the  non-operative  course  should 
first  be  tried;  and  should  this  fail,  the  more  radical  way  remains 
open  to  the  surgeon.  But  iu.  case  of  children,  who  are  the  usual 
subjects  of  such  laryngeal  injury,  the  laryngoscopist  would  find  it 
hard  to  carry  out  his  treatment.  In  such  patients,  tracheotomy 
should  first  be  done;  and  then  through  the  tracheal  fenestra,  the 
conservation  of  the  calibre  of  the  laryngeal  passage  might  be 
accomplished  by  the  passage  from  below  upwards  of  an  elastic 
sound:  and  if  a  stricture  has  already  formed,  then  the  writer 
suggests  that  through  the  tracheal  opening  dilating  sounds 
might  be  passed,  and  the  calibre  finally  enlarged  to  satisfactory 
dimension.  If  an  opening  into  the  air-passage  be  made  by 
crico-tracheotomy,  then  through  this  sub-laryngeal  route,  the 
treatment  referred  to  could  easily  and  successfully  be  carried  out; 
and  when  the   laryngeal  > canal   is   restored,  then   the  tracheal 


LARYXGOTOMY.  1073 

wound  could  be  closed.  But  in  case  the  stricture  has  already 
formed,  then  the  narrowed  calibre  can  often  be  restored  by 
gradual  dilatation,  by  means  of  instruments  introduced  through 
the  mouth  and  throat:  and  this  work,  to  be  effective,  must  be 
done  with  infinite  gentleness  and  patience;  for  the  laryngologist 
and  the  urethral  surgeon  have  both  learned  that  a  narrowed 
canal  cannot  be  hastily  restored  to  normal  calibre,  and  that  the 
compressive  action  of  tlie  instrument,  gently  manipulated  and 
long  used,  finally  causes  absorptive  action  in  the  encroaching 
wall.  Should  this  plan  be  impracticable,  or,  for  some  cause,  not 
be  feasible,  then  tracheotomy  must  be  done,  and  a  canula  worn 
until  healing  has  taken  place:  and  when  this  has  taken  place, 
it  will  be  necessary  afterwards  to  practice  endo-laryngeal  dila- 
tation. 

And  finally,  as  indication  for  laryngotomy  is  the  presence  of  a 
neoplasm  within  the  larynx.  Until  recently,  it  was  not  thought 
possible  to  remove  such  growth  in  any  way,  except  to  open  a 
route  to  it  with  the  knife:  but  the  increased  adroitness  of  the 
laryngoscopist,  in  discovering  and  attacking  such  neoplasm  by 
the  bloodless  endo-laryngeal  way,  has  rendered  a  resort  to  the 
surgical  method  a  rarer  procedure  than  formerly.  Bruns,  a 
partisan  of  the  former  method,  has  collected,  within  a  period  of 
twenty-five  years,  one  thousand  cases  of  laryngeal  tumor,  removed 
by  the  endo-laryngeal  method:  and  during  the  same  time,  there 
were  but  one  hundred  operations  in  which  the  removal  was 
done  by  opening  the  larynx.  These  statistics  show  that  the 
laryngoscopic  plan  is  greatly  in  the  ascendant:  nevertheless, 
the  better  method  to  be  pursued  in  the  removal  of  these  growths 
will  be  indicated  by  their  location  in  the  larynx,  and  by  their 
nature:  for  in  certain  locations,  the  neoplasm  is  nearly  or  quite 
inaccessible  by  the  natural  way;  and,  if  it  be  of  malignant 
character,  its  extirpation  could  be  less  radically  done  by  this 
method,  than  by  laryngotomy. 

Bruns  studied  the  location  of  the  endo-laryngeal  growth  in 
eleven  hundred  cases,  and  he  finds  that  in  eight  hundred  and 
thirty-six,  or  about  seventy-six  per  cent  of  the  cases,  the 
neoplasm  was  on  the  vocal  cord,  or  the  anterior  commissure 
of  the  glottis:  and  this  location  is  favorable  for  the  removal  by 
the  laryngoscopist.  But  if  the  growth  be  seated  below  the  vocal 
chords,  or  if  seated  within  the  ventricle  of  the  larynx,  then  the 
work  should  be  done  by  laryngotomy.  Such  cases,  however,  are 
rare.     Again,  if  the  growth  be  of  malignant  character,  then  its 


1U74  LAKYNGOTOMY. 

removal  can  be  far  more  effectually  done  by  thyreotomy,  in 
which  the  neoplasm  being  cx{)osed  to  view,  its  removal  can  be 
more  accurately  and  safely  done. 

The  determination  of  the  nature  of  the  growth  is  not  an  easy 
matter:  the  microscope  is  not  a  faultless  mentor:  that  its  state- 
ment is  frequently  erroneous  is  a  fact  which  has  fallen  within 
the  writer's  observation,  a  number  of  times:  and  no  more  striking 
example  can  be  cited  than  the  case  of  the  late  Crown  Prince  of 
Germany,  in  whom  the  microscope  gave  a  report  that  proved  to 
be  erroneous,  though  it  was  in  the  hands  of  the  ablest  micros- 
copist  and  pathologist  of  the  century.  The  truth  is,  that 
infinite  training  and  experience  cannot  always  warrant  infalli- 
bility in  this  work;  the  eye  may  wrongly  see  what  is  within  the 
visual  field.  And,  further,  connective  tissue  and  ci)itlielial  cell 
and  intercellular  elements  do  not  always  conform  to  the  schematic 
framework  which  the  pathologist  has  constructed  for  them. 
Nature  delights  in  variation,  and  rigorously  eschews  the  thral- 
dom of  uniformity;  no  two  hands  are  alike;  no  two  vascular 
systems  agree  in  disposition:  slight  difference  or  abrupt  anomaly 
occurs ;  and  so  no  two  specimens  of  epithelioma  or  sarcoma  are 
identical;  the  bounding  line  inclosing  one  group  of  cells  in  one 
specimen  would  not  geometrically  fit  those  of  another  specimen 
of  identical  nature.  The  indefinite  bounds  between  fibroma  and 
sarcoma,  and  between  the  latter  and  carcinoma,  will  often  cause 
hesitation,  and  interfere  with  accurate  diagnosis.  Should  the 
evidence  in  favor  of  malignancy  predominate,  then  the  only  hope 
of  cure  depends  on  thorough  removal  of  the  growth;  and  for  this 
purpose  laryngotomy  offers  many  advantages  over  the  other 
method.  The  removal  should  be  complete;  suspicious  tissue 
should  not  be  spared;  and  if  partial  removal  does  not  promise  a 
cure,  then  extirpation  of  the  entire  larynx  should  be  done:  it  is 
only  by  proceeding  in  this  way,  that  the  surgeon  can  offer  his 
patient  a  hope  of  immunity  from  recurrence. 

The  sessile  or  pedunculated  form  of  the  growth  determines 
the  difficulty  or  facilit3Mn  the  removal  of  the  laryngeal  neoplasm: 
thus,  the  growth  with  footstalk  can  easily  be  plucked  from  its 
nutrient  ground;  and  such  a  case  is  well  suited  forendo-laryngeal 
extraction ;  but  when  it  is  sessile,  and  especially  if  the  growth 
be  of  multiple  form,  the  laryngoscopist  must  travel  the  tiresome 
way  countless  times,  before  he  brings  away  the  final  fragments 
of  the  growth. 

If  one  compares  the  endo-laryngeal  with  the  extra-laryngeal 


OPERATION    OF    LARYXGOTOMY.  1075 

method,  in  respect  to  the  chance  of  impairment  of  the  voice,  a 
preference  may  be  claimed  for  the  latter:  for  tiie  operator  has, 
when  the  larynx  is  opened,  directly  under  his  eye,  the  parts 
which  are  to  be  removed,  and  hence  he  can  do  it  without  peril 
to  the  vocal  chords.  The  surgeon  sometimes  finds  an  irregularly 
formed  thyroid  cartilage :  one  side  may  project  further  beyond 
the  median  line  than  the  other,  and  thus  there  is  danger  of 
injuring  the  vocal  chords  at  their  anterior  insertion,  whether  the 
section  be  done  from  the  inside  or  the  outside.  Again,  it  some- 
times occurs  that  in  healing  the  two  halves  do  not  unite  symmet- 
rically; or  the  closure  may  take  place  by  loose  ligamentous 
tissue,  and  then  the  vocal  chords  lacking  firm  insertion  in  front, 
their  function  may  thus  be  impaired.  Hence,  as  seen,  phonic 
impairment  may  follow  the  work  of  thyreotomy.  The  perils 
which  menace  the  voice  are  less  when  the  operation  is  limited  to 
partial  laryngotomy ;  that  is,  when  the  growth  is  reached  by  an 
opening  above  or  below  the  thyroid  cartilage. 

Thyreotomy  has  an  advantage  over  the  endo-laryngeal  method 
in  this,  that  the  treatment  is  concluded  in  a  shorter  time  in  the 
former.  Of  forty-four  cases  of  laryngotomy,  healing  occurred  in 
nearly  half  of  them  within  one  week;  and  in  nearly  all  of  the 
remaining  cases,  the  patients  were  well  within  two  weeks.  In  a 
few  cases,  by  the  endo-laryngeal  procedure,  the  work  may  be 
concluded  instantaneously,  yet  when  the  tumor  is  less  favorably 
situated  for  removal,  weeks  and  even  months  may  be  required  to 
effect  complete  extirpation. 

Operation  of  Laryngotomy. — In  many  cases  it  is  prudent  to 
precede  laryngotomy  by  tracheotomy;  and,  as  additional  aid, 
the  air-passage  may  be  tamponed  above  the  canula.  If  the 
vertical  division  of  the  laryrix  be  carried  below  the  thyroid 
cartilage,  then  the  canula  may  rest  in  the  lower  part  of  the  cut, 
that  is,  in  the  crico-thyroidean  space.  But,  as  a  rule,  it  is  better 
to  make  a  separate  opening  in  the  trachea  for  the  canula:  and 
then  above  this,  a  tampon  may  be  introduced,  and  allowed  to 
remain  for  two  or  three  days. 

In  the  operation  of  laryngotomy,  to  reach  the  larynx  but  a 
thin  stratum  of  soft  parts  requires  to  be  divided;  the  prominence 
of  the  larynx  lies  just  underneath  the  skin.  If  thyreotomy  be 
done,  no  vessel  is  imperiled  unless  the  knife  carelessly  stray 
beyond  the  proper  field  of  work.  Only  in  case  it  be  necessary  to 
extend  tlie  cut  into  the  crico-thyroid,  or  thethyro-hyoidean  space, 
"would  the  vessels  there  be  endangered.     And  then  such  vessel 


1O70  LAKYXGOTOMY. 

should  be  tied.  Another  element  of  embarrassment  is  an  abnor- 
mal development  of  the  thyroid  gland:  this  gland  may  have  a 
middle  lobe  reaching  upward  on  the  thyroid  cartilage.  Should 
this  be  present,  and  it  not  be  possible  to  deflect  it  aside  with  the 
blunt  dissector,  then  the  glandular  structure  should  be  circum- 
scribed by  ligature  at  two  points,  and  division  done  between  the 
ligatures. 

The  patient  to  be  operated  on  should  rest  on  a  bed  or  table 
where  he  is  accessible  on  each  side;  and  a  cushion  must  be  placed 
under  the  shoulders,  so  as  to  render  prominent  the  field  of 
operation. 

The  instruments  required  in  the  work  are  the  following: 
scali^el,  two  retractors  similar  to  those  used  in  tracheotomy,  a 
fine  saw,  scissor-shaped  forceps,  needles,  silken  thread,  sponges 
and  a  canula. 

The  work  commences  with  simple  tracheotomy:  and  if 
thought  necessary,  through  this  tracheal  wound  a  sponge  may 
be  introduced,  and  the  trachea  plugged  well,  just  above  where 
the  canula  is  to  lie.  This  preliminary  being  concluded,  the 
thyroid  cartilage  is  next  to  be  reached  and  exposed  by  an 
incision  in  the  median  line.  The  cartilage  being  in  view,  the 
manner  in  which  it  may  be  opened  will  be  determined  by  the 
age  of  the  patient.  For  example,  in  the  youthful  subject,  the 
cartilage  can  readily  be  divided  with  a  strong  knife,  and  this  can 
be  dune,  in  the  median  line,  from  before  backwards.  If  the 
cartilage  has  become  partly  or  wholly  ossified,  as  is  the  condition 
in  the  old  subject,  then  the  division  is  not  so  easily  done.  The 
instrument  for  the  work  may  then  be  a  fine,  narrow-bladed  saw, 
such  as  is  used  in  resection  of  bone;  or  a  strong  knife,  if  wielded 
by  a  strong  hand,  will  answer  the  purpose.  And  such  ossified 
cartilage  is  divided  from  the  outside  inwards,  by  some  operators: 
others  divide  from  within  outwards;  and  in  this  case,  a  probe- 
pointed  knife  is  used.  To  use  the  blunt  knife,  let  an  opening  be 
made  at  the  upper  or  lower  border  of  the  tliyroid  cartilage,  in 
the  median  line;  and  through  the  opening  insert  the  knife  and 
then  make  the  division  from  behind  forwards.  This  is  the 
method  devised  by  Sclmller  and  Hueter.  If  the  small  saw  is 
used,  its  track  should  first  be  prepared  by  a  division  of  the 
mucous  membrane  with  the  knife.  Instead  of  knife  or  saw,  the 
section  may  be  made  with  narrow-bladed  bone  forceps,  or  with 
strong  narrow-bladed  scissors. 

After  this  division  of  the  thyroid  cartilage,  should  the  space 


OPERATION    OF    LARYNGOTOMY.  1077 

exposed  be  found  insufficient  to  do  the  work  intended,  then  the 
section  of  the  parts  may  be  continued  upwards,  or  downwards- 
and  in  the  latter  direction,  the  cricoid  cartilage  may  be  severed. 
And  after  this  complete  laryngotomy,  or  after  the  division  of  the 
thyroid  cartilage,  should  the  space  be  inadequate  for  the  removal 
of  the  laryngeal  growth,  or  too  small  for  any  other  purpose  for 
which  the  opening  is  done,  then  a  portion  of  one  or  both  sides  of 
the  thyroid  cartilage  may  be  exsected.  Such  exsection  was  done 
by  Heine;  and  his  plan  is  as  follows:  after  the  median  cutane- 
ous incision  has  been  made,  and  the  cartilage  having  been 
reached  has  been  divided  vertically,  then  let  the  cartilage  be 
freed  from  its  lining,  both  internally  and  externally,  and  next, 
with  strong  scissors  or  resection  forceps,  remove  the  required 
portion  of  cartilage. 

The  excision  of  a  portion  of  the  thyroid  cartilage  may  enable 
the  operator  to  enter  the  larynx  and  do  his  work  without  further 
division  of  the  parts:  that  is,  a  window  may  be  made  at  a  point, 
which  the  laryngoscopic  examination  indicates  will  render  the 
growth  most  readily  accessible  to  the  surgeon;  and  as  this  may 
be  at  the  lower  or  upper  margin,  so  a  corresponding  cut  is  to  be 
made,  the  larynx  uncovered  of  its  soft  parts,  and  then  a  portion 
of  the  wall  is  excised.  The  location  of  such  opened  fenestra 
should  be  such  as  not  to  interfere  with  the  vocal  chords. 

According  to  the  purpose  for  which  the  laryngotomy  has  been 
done,  so  will  the  operator  proceed  when  the  cavity  has  been 
opened:  whether  the  case  be  one  of  neoplasm,  of  stricture,  or  of 
dead  cartilage,  the  surgeon  should  bear  in  mind  that  his  work 
should  be  well  and  thoroughly  done:  so  completely  done  that 
there  will  be  no  occasion  for  another  operation.  Still  a  lar3a]got- 
omy  has  been  done  a  second  and  even  a  third  time,  on  the  same 
patient:  but  it  were  better,  for  both  patient  and  surgeon,  that  the 
work  should  be  so  fully  done  as  to  exclude  such  future  contin- 
gency. 

How  the  wound  is  to  be  closed  has  been  a  matter  of  disagree- 
ment among  surgeons :  some  favor  and  others  oppose  closure  by 
suture.  Against  the  use  of  the  suture  its  opponents  urge  that  it 
may  cause  emphysematous  infiltration  of  air  in  the  wounded  tis- 
sues; also,  that  the  suture  may  be  the  cause  of  necrosis  in  the 
cartilage.  Krishaber  reports  such  emphysema  in  a  case  in  which 
suture  was  used.  That  the  ill  which  may  arise  from  suture  has 
been  magnified,  is  apparent  from  the  results  obtained  in  thirty- 
five  cases  so  treated  :  in  twenty-nine  of  these,  the  wounded  carti- 


1078  LARYNGOTOMY. 

lage  united  by  first  intention;  and  only  in  five  of  the  cases  was 
the  healing  prolonged  by  suppuration. 

Where  suture  is  used  for  closure,  silk  or  wire  may  be 
employed :  the  author  would  use  silver  wire,  in  case  it  is  intended 
to  penetrate  the  entire  thickness  of  the  cartilage.  But  in  case 
merely  the  lining  membrane  of  the  cartilage  is  traversed,  then  it 
is  immaterial  whether  silken  or  metallic  suture  be  employed.  In 
case  steady  fixation  of  the  parts  can  be  made  by  simply  including 
the  perichondrium,  it  should  be  done  in  this  manner:  and  expe- 
rience has  shown  that  this  superficial  suture  suffices.  After  the 
laryngeal  wound  has  been  closed,  the  wound  in  the  skin  and 
soft  parts  must  be  closed  by  more  superficial  sutures. 

Closure  of  the  wound  can  often  be  satisfactorily  done  without 
the  use  of  sutures,  namely,  by  adliesive  strips  placed  transversely 
across  the  part;  and  these  may  be  aided  by  compresses  laid  on 
each  side,  and  the  whole  retained  in  place  by  means  of  a  bandage 
around  the  neck. 

The  canula  inserted  in  the  preliminary  tracheotomy  should 
remain  in  place  in  children  for  a  time  varying  from  a  few  days 
to  some  weeks:  thus  doing,  one  guards  against  respiratory 
obstruction  through  intra-laryngeal  swelling.  In  the  adult,  it 
is  sometimes  necessary  to  let  the  instrument  remain  in  place 
many  weeks:  and  in  some  cases  it  has  been  found  necessary  to 
let  the  canula  remain  in  j)osition  for  months,  and  sometimes  for 
years.  The  prolonged  use  of  the  canula  is  required  in  the  adult 
in  whom  the  endo-laryngeal  growth  may  so(5n  recur,  and  sud- 
denly obstruct  the  air-passage. 

In  concluding  this  cliapter  upon  laryngotomy,  the  writer  will 
formulate  as  a  rule  of  guidance,  that  in  all  cases  in  which  the 
operation  is  contemplated,  a  consultation  should  be  held  between 
the  laryngoscopist  and  surgeon,  and  if  in  the  opinion  of  the 
former,  the  case  can  surely,  or  even  probably,  be  successfully 
treated  by  the  endo-laryngeal  method,  then  the  latter  should  be 
pursued:  but  incase  this  method  be  deemed  impracticable,  or 
have  failed  in  its  purpose,  then  the  case  should  be  committed  to 
the  surgeon,  and  one  of  the  methods  heretofore  described,  be 
pursued. 

INTUBATION. 

About  1858,  Bouchut  advised  as  a  substitute  for  trache- 
otomy, the  introduction  of  a  tube  or  canula  into  the  larynx. 
In  1859,  Trousseau  who  had  gained  great  eclat  by  his  successful 


INTUBATIOX.  1079 

operations  in  tracheotomy,  and  was  the  leading  champion  of  this 
operation,  violently  opposed  the  new  procedure  of  Bouchut. 
Trousseau  founded  his  opposition  on  the  observations  of  dogs,  in 
which  such  tube  was  introduced  into  the  larynx,  and  worn  for 
some  days,  with  the  result  that  the  tube  caused  ulceration  of  the 
glottis,  and  if  it  were  to  remain  long  in  place  Trousseau  claimed 
that  it  would  cause  necrosis  of  the  larynx.  The  high  authority 
of  Trousseau,  and  the  general  antagonism  of  the  medical  profes- 
sion in  Paris  to  Bouchut,  prevented  the  adoption  of  intubation  as 
a  method  of  relief  in  croup  and  diphtheria.  Bouchut,  though 
deprived  of  his  well-merited  honor,  lived  to  see  the  method 
revived  and  adopted  in  the  New  World. 

In  1870,  Weinlechner,  of  Vienna,  resorted  to  intubation  in  the 
treatment  of  croup  and  diphtheria.  He  first  tried  the  plan  of 
passing  a  solid  sound  into  the  air-passage,  and  with  this,  he 
attempted  to  remove  the  impediment  existing  there :  and  this 
failing  to  relieve,  he  next  passed  a  tube  that  was  closed  by  an 
obturator,  and  when  introduced,  the  latter  was  removed,  and  the 
tube  allowed  to  remain.  So  much  benefit  was  derived  from  this 
procedure  that  Weinlechner  recommends  that  it  be  tried  before 
tracheotomy  is  resorted  to.  Besides  in  croup  and  diphtheria,  he 
recommends  tubage  in  oecleraa  of  the  glottis,  laryngo-spasmus, 
as])hyxia,  stricture  of  the  larynx  or  trachea,  and  foreign  bodies 
in  the  air-passages. 

Despite  the  attempts  to  substitute  tubage  or  intubation,  as  it 
is  now  generally  named,  for  tracheotomy,  the  procedure  fell  into 
disfavor  and  was  soon  abandoned.  In  1884  it  was  again  called 
to  life  by  Dr.  Joseph  O'Dwj^er,  to  whom  more  credit  is  due  than 
to  an  originator,  since  in  his  work  he  has  reclaimed  a  procedure 
that  had  twdce  or  thrice  been  tried  and  rejected.  O'Dwyer's 
early  attempts  were  not  crowned  by  remarkable  success;  yet  it 
was  enough  to  direct  the  attention  of  the  profession  to  the  method, 
and  to  enlist  a  few  followers.  Among  those  who  adopted  and  did 
much  to  popularize  the  procedure  may  be  mentioned  Dr.  Wax- 
ham,  of  Chicago,  and  Dr.  Dillon  Brown,  of  Xew  York.  Early  in 
1885,  Dr.  Waxham,  an  ardent  advocate  of  intubation,  read  a  paper 
on  the  subject,  before  the  Chicago  Medical  Society;  and  later  in 
the  year,  he  read  another  paper,  in  which  were  detailed  the 
results  obtained  in  a  few  cases.  Some  improvements  had  been 
made  in  the  instruments  first  employed.  Dr.  Byford  also  praised 
the  method,  for  its  simplicity,  safety  and  the  immediate  relief 
obtained;  and  another  strong  point  in  its  favor  is  that  the  opera- 


1080  LARYNGOTOMY. 

tion  is  less  objectionable  to  i^arents  than  that  of  tracheotomy. 
About  the  same  time,  O'Dwyer  reported  two  successful  cases,  in 
which  the  tube  had  been  worn  ten  days.  No  oedema  of  the 
larynx  was  caused  by  the  tube.  In  very  young  children  he  coun- 
sels to  occasionally  remove  the  tube  and  cleanse  it. 

In  188G,  Dr.  Dillon  Brown,  of  New  York,  having  collected 
eight  hundred  and  six  cases  of  intubation,  read  a  paper  on  the 
subject  before  the  New  York  Academy  of  Medicine.  The  num- 
ber of  medical  men  who  had  employed  the  procedure  were  sixty- 
five ;  the  recoveries  obtained  were  two  hundred  and  twenty-one, 
that  is,  about  twenty-seven  and  five-tenths  per  cent.  The  average 
age  of  those  who  died  was  three  years  and  two  months;  and  of 
those  who  recovered,  a  little  over  four  years.  The  average  dura- 
tion of  the  laryngeal  trouble,  before  the  introduction  of  the  tube, 
in  those  who  died  was  one  day  and  nineteen  hours;  and  in  those 
who  recovered  it  was  two  days  and  nine  hours.  The  usual  cause 
of  death  was  the  passage  downwards  of  the  diphtheritic  disease. 
The  advantages  claimed  by  Brown  for  intubation  are  that  the 
operation  is  bloodless,  the  air  in  breathing  is  admitted  through 
the  natural  route,  there  is  no  shock,  and  the  procedure  incurs  no 
opposition  from  the  parents  or  friends  of  the  child. 

Northrop  has  made  post-mortem  examination  in  one  hundred 
and  seven  cases  in  which  intubation  had  resulted  unsuccessfully. 
In  a  few  cases,  the  lower  end  of  the  tube  had  caused  ulceration 
of  the  trachea. 

Huber  found  that  after  the  introduction  of  the  tube,  it  might 
be  coughed  up;  and  even  coughed  up  and  swallowed.  The  tube 
may  also  become  closed  with  false  membrane.  In  swallowing 
food,  particles  of  matter  may  enter  the  tube,  and,  passing  down  to 
the  lungs,  become  the  cause  of  pneumonia.  Huber  saw  ulcera- 
tion and  bleeding  caused  by  the  tube.  Swallowing  is  difficult; 
and  sometimes  the  breathing  is  suddenly  arrested.  And  the 
most  improved  forms  of  the  tube  have  not  guarded  against  the 
troubles  mentioned. 

The  instruments  used  by  O'Dwyer  for  intubation,  shown  in 
the  accompanying  figure,  are  the  following:  assorted  tubes  (A), 
varying  from  small  to  large;  an  applicator  (D)  or  instrument 
which  is  attached  to  an  obturating  stem,  and  by  the  aid  of  which 
the  tube  is  inserted  into  the  larynx;  a  gag  (C)  for  holding  the 
jaws  asunder,  and  the  mouth  open;  an  extractor  (E),  by  the  aid 
of  which  the  tube  (A)  is  seized  and  withdrawn;  and  a  gauge  (B) 
for  admeasurement. 


INTUBATION. 


1081 


Of  the  tubes  there  should  be  five  of  differmg  calibre,  and 
lengths  varying  from  one  and  three-fourths  to  two  and  a  half 
inches.  The  tube  lias  attached  to  it  a  silken  thread  by  which  it 
is  held  and  withdrawn,  if  in  the  work  of  insertion  it  is  not  prop- 
erly placed:  but  when  the  insertion  is  properly  done,  the  loop  of 
the  thread  is  cut,  and  the  latter  removed. 

In  the  work  of  introducing  the  tube,  the  hand  of  the  opera- 


FiGUEE  106.    Exhibiting  O'Dwyer's  instruments  for  intubation. 

tor  should  have  previous  training  on  the  cadaver;  for  to  attempt 
the  introduction  without  some  preliminary  training,  will  be 
attended  with  much  bungling  effort,  and  may  end  in  failure. 
The  index  must  be  taught  to  recognize  the  hard  cartilaginous 
entrance  into  the  larynx,  and  to  distinguish  this  opening  from 
that  of  the  gullet :  for  the  mistake  oftenest  occurring  in  the  intro- 
duction is  to  place  the  tube  in  the  oesophagus,  instead  of  in  the 
larynx:  yet  by  means  of  the  tethering  thread,  the  tube  can  be 
drawn  back  and  replaced  again. 

The  fear  was  entertained  for  a  time  that  the  tube  might  slip 
downwards  through  the  glottis  into  the  air-passages;  to  avoid 
this  the  tube  is  now  provided  with  a  larger  shoulder  around  its 
mouth.  And,  as  Ingalls  remarks,  even  should  the  tube  pass  down 
into  the  air-passages,  its  length  is  such  as  to  prevent  it  escaping 
so  far  that  it  could  not  be  reclaimed  through  the  natural  route; 
or,  this  failing,  it  might  be  removed  by  tracheotomy.  The 
length  of  the  tube  is  such  that  it  reaches  to  within  one  inch  of  the 
bifurcation  of  the  trachea. 
d9 


iOS2  LAKYXGOTOMY. 

The  applicator  and  the  obturating  appendage  are  to  be 
attached,  and  then  the  tube  being  placed  on  the  former,  the 
instrument  is  ready  for  insertion. 

To  introduce  the  tube,  let  the  child  be  held  in  the  nurse's  lap 
wrapped  about  with  a  cloth  that  securely  incloses  tlie  arms.  An 
assistant  firmly  holds  the  head  turned  backwards,  while  the  gag 
is  introduced,  well  back  on  the  left  side  of  the  mouth.  The 
surgeon  sitting  in  front  passes  his  left  index  finger  into  the 
throat  behind  the  epiglottis  and  seeks  for  the  opening  into  the 
larynx;  and  holding  the  finger  there  he  guides  the  tube  along 
its  palmar  surface,  into  the  glottis.  When  the  tube  has  been 
inserted  to  its  shoulder,  a  slide  on  the  applicator  is  pushed 
against  the  latter,  and  then  the  applicator  being  withdrawn,  the 
tube  is  left  in  the  destined  position.  In  this  work  of  insertion, 
O'Dwyer  advises  to  commence  with  the  handle  of  the  applicator 
near  the  child's  breast,  and  then  gradually  to  lift  the  handle  as 
the  introduction  advances;  thus  elevating  well  the  handle,  there 
is  less  danger  of  slipping  the  tube  into  the  oesophagus.  As  soon 
as  the  tube  has  been  introduced,  after  the  obturator  and  appli- 
cator have  been  extracted,  the  child  wall  soon  breathe  easier. 

Should  the  tube  become  obstructed  with  mucus  or  false 
membrane,  it  must  be  removed  with  the  extractor,  cleaned  and 
re-inserted.  As  a  rule,  the  tube  should  be  removed  as  early  as 
the  fifth  day,  and  a  test  made  of  the  patient's  condition;  and 
should  breathing  remain  free,  the  tube  may  be  dispensed  with; 
but  should  dyspnoea  reappear,  then  the  tube  must  be  inserted 
again. 

A  critical  contingency  sometimes  occurs  during  the  wearing 
of  the  tube,  viz.,  that  the  latter  is  expelled  by  coughing  :  and  at 
the  time  of  such  accident,  if  the  surgeon  is  not  present  to  replace 
the  instrument,  the  patient  may  be  lost:  and  hence,  here,  as  in 
case  of  tracheotomy,  there  must  be  ever  at  hand  an  assistant  or 
nurse,  who  is  capable  of  meeting  the  emergency;  and  such  an 
aid,  if  not  a  medical  man,  should  be  someone  who  has  had 
medical  training,  and  especially  in  the  work  of  inserting  the  tube- 

Ingalls,  an  early  reporter  on  intubation,  selects  the  following 
cases  as  pro})er  fur  its  use : — 

1.  In  diphtheritic  and  croupous  stenosis  of  tlie  larynx  in 
children  under  three  and  one-half  years  of  age.  2.  In  cases  of 
these  affections  in  which  the  surgeon,  from  any  cause,  desires  to 
defer  tracheotomy.  3.  In  thpse  cases  in  which  consent  to  tra- 
cheotomy cannot  be  obtained.     4.  Those  cases  in  which  proper 


INTUBATION.  1083 

nursing  cannot  be  obtained.  5.  Severe  cases  of  spasmodic 
croup  in  children  less  than  ten  years  of  age.  6.  Simple 
stenosis  of  the  larynx,  not  diphtheritic,  in  children.  7.  With 
tubes  of  proper  size  it  might  be  of  value  in  the  treatment 
of  various  forms  of  laryngeal  stenosis  in  adults.  He  intimates 
that  a  formidable  risk  in  intubation  is  the  coughing  out  of  the 
tube,  in  the  absence  of  any  one  who  could  re-insert  it.  Ingalls 
thinks  intubation  is  especially  suited  for  small  children,  since  in 
these  tracheotomy  is  usually  unsuccessful.  As  large  a  tube  as 
possible  should  be  used,  since  one  of  less  than  one-fourth  of  an 
inch  in  diameter  does  not  permit  enough  air  to  pass  to  main- 
tain life. 

Casselberry  thinks  a  part  of  the  success  of  O'Dwyer's  proced- 
ure depends  on  the  use  of  a  long  tube:  the  short  tube  employed  by 
Bouchut  rendered  it  difficult  to  be  used,  and  caused  the  method 
to  be  abandoned.  Casselberry  fears  that  trouble  will  arise  in 
feeding  children  who  are  the  subjects  of  intubation;  and  that 
when  the  food  is  liquid,  some  of  it  will  enter  the  air-passage. 
On  this  point,  Parkes  thinks  there  will  not  be  much  difficulty  if 
a  tube  be  so  selected  that  it  will  fit  well,  and  permit  the  epiglottis 
to  close  well  over  it  in  swallowing. 

According  to  Northrop,  the  beginner  in  the  practice  of  intuba- 
tion is  apt  to  use  too  small  tubes,  with  the  result  that  such  are 
coughed  up.  He  says  there  is  no  risk  of  the  instrument  slipping 
down  into  the  trachea,  since  the  head  of  the  tube  cannot  pass 
beyond  the  cricoid  cartilage,  where  the  narrowest  portion  of  the 
passage  is  situated.  He  cautions  against  premature  removal  of 
the  tube.  After  the  removal  of  the  tube,  whether  it  will  be 
necessary  to  re-introduce  it,  will  depend  on  whether  the  air  canal 
remains  free  from  obstructing  membrane,  or  the  lungs  continue 
unaffected.  The  re-appearance  of  pseudo  membrane  demands 
re-insertion  of  the  tube;  and  if  ausculation  shows  that  the  lungs 
are  becoming  impeded  in  their  work,  then  the  tube  must  be  used 
again.  The  pulse  gives  some  information;  its  rapidity  corre- 
sponding with  pulmonary  implication  is  an  indication  for  intuba- 
tion. The  objection  is  urged  sometimes  that  in  the  insertion  of 
the  tube,  false  membrane  may  be  pushed  before  it  and  occlude 
the  tube;  the  same,  according  to  Northrop,  applies  also  to 
tracheotomy.  Intubation  has  the  advantage  over  tracheotomy, 
that  it  can  be  done  without  an  anaesthetic.  Another  advantage 
which  it  has  is,  that  the  air  enters  the  mouth  and  is  warmed  and 
moistened  before  it  enters  the  lungs. 


1084  LARYXiiOTOMY. 

Xear  the  close  of  the  year  1893,  Waxham  reported  the  results 
of  intubation  in  four  liuntlred  and  sixty-six  cases:  in  the  first 
one  hundred  there  were  twenty-seven  recoveries;  in  the  second 
one  hundred,  thirty-four  recoveries;  in  the  third  one  hundred, 
forty  recoveries;  in  the  fourtli  one  hundred,  thirty-eight  recov- 
eries; and  of  the  last  sixty -six  cases,  twenty-two  recovered.  The 
assertion  that  intubation  is  done  early,  and  hence  is  more  success- 
ful than  tracheotomy,  Waxham  denies:  for  in  many  of  the  cases 
which  he  reported,  it  was  done  late,  when  the  child  was  moribund 
and  unconscious:  and  in  many  patients  to  which  he  was  sum- 
moned, the  children  were  dying,  and  expired  before  anything 
could  be  done.  The  cases  reported  were  not  selected  ones,  but 
were  of  ages  varying  from  early  infancy  to  much  older  children, 
and  had  been  treated  by  physicians  who  had  tried  unsuccessfully 
to  relieve  the  patients  by  other  means.  And  many  of  them  were 
among  the  poor  and  destitute  and  were  badly  nursed;  even  under 
such  conditions,  the  results  obtained  were  very  satisfactory. 

The  instruments  employed  were  an  improvement  on  those 
originally  introduced :  the  introducer  could  be  used  more  readil}'^; 
the  obturator  was  not  jointed,  as  it  was  in  the  original  form. 
The  instruments  were  purely  metallic;  and  also  the  case  which 
contained  them,  so  that  all  could  be  washed  in  hot  water,  and 
rendered  aseptically  free  from  the  bacterial  virus  with  whicli 
they  must  come  in  contact  in  the  treatment  of  croupal  or  diph- 
theritic disease. 

At  the  sixty-fifth  meeting  of  the  Association  of  German 
Naturalists  and  Physicians,  lianke,  in  the  section  of  diseases  of 
infants,  made  an  exhaustive  report  on  intubation;  and  drew  a 
comparison  between  intubation  and  tracheotomy.  The  figures 
presented  by  those  who  engaged  in  the  discussion  varied  much 
in  regard  to  success:  and  this  is  explained  as  de|)endent  on  the 
benign  or  malignant  type  of  the  diphtheritic  disease,  for  whicli 
the  tubage  was  done.  In  the  cases  reported,  the  procedure  was 
only  resorted  to  when  the  larynx  had  become  so  occluded  with 
false  membrane  that  tracheotomy  would  have  been  necessary  to 
prolong  life,  if  intubation  had  not  been  done.  All  cases,  without 
reference  to  age,  were  operated  on,  and  the  whole  number  reported 
amounted  to  twenty-five  hundred. 

The  cases  operated  on  were  classified  as  those  of  primary  and 
those  of  secondary  diphtheria;  in  the  former,  the  recoveries  from 
intubation  were  thirty-nine  ])er  cent;  while  from  the  latter  there 
were  twenty-two  and  three-tenths  per  cent  of  recoveries.     Of  one 


INTUBATION.  1085 

thousand  three  hundred  and  twenty-four  cases  of  primary  diph- 
theria in  which  intubation  was  done,  it  was  afterwards  necessary 
to  perform  tracheotomy  in  two  hundred  and  fort3'-two  patients; 
and  of  these  over  eight  per  cent  w^ere  saved;  and  that  a  greater 
number  was  not  saved  arose  from  the  disease  having  descended 
into  the  bronchi. 

Ranke  thinks  that  intubation  is  especially  suited  for  the 
country  practitioner  whose  surgical  skill  is  insufficient  to  perform 
tracheotomy.  He  thinks  that  in  the  country  there  might  be 
saved  twenty-five  per  cent  of  diphtheritic  patients,  which  ordi- 
narily die. 

In  instituting  a  comparison  between  intubation  and  tracheot- 
omy, the  number  of  recoveries  obtained  by  the  two  methods  is 
about  equal.  In  children  under  two  years  of  age,  there  are  more 
recoveries  by  intubation  than  by  tracheotomy;  hence,  intubation 
should  be  done  in  the  very  young. 

In  cases  of  diphtheria  in  which  the  membranous  formation  is 
very  extensive,  and  the  pharynx  is  much  swollen,  Widerhofer 
advises  tracheotomy;  also,  to  avoid  ulceration  from  the  tube,  in 
cases  in  which  this  must  be  carried  for  more  than  five  days,  he 
advises  that  intubation  should  be  followed  by  tracheotomy. 
When  the  membranous  formation  extends  downwards  towards 
the  lungs,  only  in  very  strong  children  should  tracheotomy  be 
resorted  to  as  subsidiary  aid.  In  the  course  of  intubation,  should 
asphyxia  suddenly  appear,  tracheotomy  should  be  done:  for 
through  the  tracheal  incision,  the  surgeon  can  often  extract  the 
false  membrane;  or  the  laryngeal  tube  being  removed,  the 
patient  is  able  to  cough  out  the  membrane. 

The  general  opinion  expressed  by  the  German  physicians  was 
that  intubation  is  a  valuable  procedure,  and  that,  by  it,  the 
prediction  of  Malgaigne  will  be  fulfilled,  viz.,  tubage  will  one  day 
bring  as  great  a  revolution  in  the  treatment  of  croup  as  lithotrity 
has  brought  in  the  treatment  of  vesical  calculus. 


CHAPTER    XXXIII. 


JiXTIRPATION  OF  THE    LAKY>'X  OR    OPERATION    OF    LARYNGECTOMY. 

The  removal  of  the  larynx  by  the  knife,  was  suggested  some 
time  before  it  was  done;  and  the  final  realization  of  this  bold 
procedure  was  rendered  possible  by  experiments  on  the  dog.  In 
1870,  it  was  proved  from  operations  on  the  dog  by  Czerny,  that 
the  larynx  could  be  removed,  and  the  animal  continue  to  live: 
and  his  results  justified  him  in  believing  that  the  operation  could 
also  be  safely  done  on  man.  Long  prior  to  Czerny's  work,  Albers 
in  Bonn  did  similar  work  on  the  dog,  with  the  object  of  deter- 
mining wd] ether  the  animal  could  live  without  the  larynx.  And, 
finally,  when  the  operation  had  been  done  on  man,  other  sur- 
geons, and  among  them  Yon  Langenbeck,  announced  that  they 
had  previously  conceived  its  possibility,  and  had  even  planned 
to  remove  the  human  larynx. 

The  first  operation  was  done  by  Billroth  in  1S73,  who  did  it 
for  relief  in  a  case  of  carcinoma  of  the  larynx.  In  this  patient, 
laryngotomy  had  been  performed  to  remove  the  endo-laryngeal 
neoplasm;  but  four  weeks  afterwards,  the  growth  reappeared, 
when  Billroth  proceeded  to  dissect  the  larynx  from  the  contigu- 
ous parts,  and  having  removed  it,  the  patient  was  provided  with 
an  artificial  larynx  by  means  of  which  he  was  able  to  talk.  This 
patient  lived  in  fair  health  for  some  months,  yet  the  carcinoma 
returned,  and  death  occurred  about  a  year  after  the  operation. 
This  operation,  in  which  the  larynx  was  removed  and  replaced 
by  an  artificial  appliance  for  phonation,  attracted  the  eyes  of  the 
surgical  world:  and  it  was  believed  that  if  the  work  were  timely 
done,  the  subject  of  laryngeal  cancer  might  be  rescued  from 
a  malady,  which  had  hitherto  been  regarded  incurable:  and  ani- 
mated with  this  hope,  or  inspired  with  the  desire  to  be  among 
the  first  in  this  new  field  of  daring,  a  number  of  surgeons  has- 
tened to  repeat  the  new  operation.  Heine  in  Prague,  Maas  in 
Breslau,  and  Bottini  in  Italy,  reported  each  an  extirpation.  In 
the  case  of  Bottini,  the  disease  was  sarcoma;  and  after  the 
( 1086 ) 


EXTIRPATION    OF    THE   LARYNX.  1087 

removal,  the  patient  was  attacked  with  erysipelas,  which  delayed 
the  recovery.  The  man  finally  became  well  and  resumed  his 
former  occupation  as  letter-carrier.  The  attack  of  erysipelas, 
now  regarded  as  antidotal  to  malignant  disease,  may  have 
stamped  out  all  traces  of  the  disease  which  had  escaped  the  knife. 

Since  these  pioneer  operations,  the  extirpation  of  the  larynx 
has  been  announced  in  all  parts  of  the  globe,  in  which  surgery 
exists  as  a  cultivated  science  and  art.  The  published  results, 
though  not  flattering,  have  been  sufficiently  encouraging  to  give 
this  procedure  an  enduring  place  in  surgical  art. 

Before  having  recourse  to  so  radical  a  procedure,  the  surgeon 
does  wisely  who  first  opens  the  larynx  by  a  vertical  incision  in  the 
median  line,  and  endeavors  to  remove  the  affected  parts  through 
such  an  opening:  in  fact,  in  the  history  of  laryngeal  extirpation, 
one  finds  that  in  many  cases  it  has  been  preceded  by  thyreotomy, 
by  which  the  neoplasm  being  removed  and  having  recurred  at 
an  early  period,  the  more  radical  procedure  of  total  extirpation 
has  been  done.  And  a  proper  rule  for  observance  in  cases  which 
have  applied  for  relief  early  in  the  disease,  is  to  first  perform 
thyreotomy;  and  should  the  disease  afterwards  recur,  the  surgeon 
is  justified  in  resorting  to  a  more  extensive  operation:  wliich  may 
be  removal  of  one  side,  or  the  whole  of  the  larynx.  If  it  be  pos- 
sible to  limit  the  ablation  to  one  side,  or  one-half  of  the  part, 
the  patient  will  be  left  in  a  much  more  favorable  state  for  the 
introduction  of  an  artificial  vocal  apparatus,  than  if  the  whole 
larynx  be  extirpated.  Hence,  from  what  has  been  said,  the 
extent  to  which  the  knife  will  proceed  in  laryngeal  extirpation  is 
to  be  learned  and  decided  on,  as  the  surgeon  proceeds  with  his 
work:  one-fourth,  one-half,  two-thirds,  or  the  whole,  as  the  con- 
ditions denote  and  demand. 

As  stated,  the  operation  is  done  for  the  removal  of  malignant 
disease,  viz.,  carcinoma  or  sarcoma ;  and  it  is  important  to  note 
that  the  results  of  operations  in  the  two  are  different:  the  pros- 
pects of  a  removal  securing  future  immunity,  are  much  more 
promising  in  sarcoma  than  in  carcinoma;  the  latter  has  almost 
always  returned,  while  permanent  cures  have  followed  the  extir- 
pation of  sarcoma. 

As  an  adjuvant  and  prophylactic  preliminary  to  extirpation 
of  the  larynx,  tracheotomy  has  been  done  by  most  operators: 
thus  certain  provision  for  respiration  during  the  work  is  secured. 
Some  operators  have  done  this  a  few  days  prior  to  the  extirpa- 
tion ;  and  this  plan  seems  to  be  a  good  one,  since,  thereby,  famil- 


1088  EXTiurATiox  OF  Tin-:  j>ai;ynx. 

iarity  with  this  unusual  route  of  breathing  is  early  acquired ;  and 
it  is  likewise  claimed  that  there  results  from  this  wounding  of 
the  cervical  structures  an  adherence  of  the  trachea  to  the  sur- 
rounding structures,  so  that  it  will  not  sink  downwards,  to  much 
extent,  after  the  removal  of  the  larynx.  The  site  of  the  trache- 
otomy must  be  as  low  as  possible;  for  thus  done,  it  will  be 
removed  from  the  operative  field ;  and  this  low  site  offers  another 
important  advantage,  that  it  permits  tamponing  the  passage 
above  the  canula,  so  that  no  blood  or  subsequent  excreta  can 
enter  the  air-passage,  and  generate  pneumonic  trouble.  The 
occlusive  tampon  of  Trendelenberg  was  used  in  extirpation  of  the 
larynx  by  Czerny,  Heine,  Wegner  and  others,  and  is  advised  by 
them;  others  have  operated  on  the  patient  placed  in  the  Rose 
position,  and  thereby  diverted  the  passage  of  blood  from  the  air- 
passages. 

In  the  absence  of  a  specially  devised  tampon,  the  closure  of 
the  upper  end  of  the  trachea  can  be  done  by  means  of  sponge 
which  has  been  purified  by  immersion  in  alcohol  diluted  with 
four  parts  of  water:  one  or  more  pieces  of  sponge  with  cord 
attached  may  be  forced  into,  and  made  to  fill  tlje  upper  end  of, 
the  trachea.  Foulis,  of  Glasgow,  successfully  performed  laryn- 
gectomy;  and  as  tampon  he  used  a  large  leaden  tube,  which 
completely  filled  the  trachea  above  the  opening  made  in  the 
provisional  tracheotomy,  and  was  closed  by  India  rubber  in  the 
shape  of  a  plate.  This  occlusion  is  done  after  the  patient  bus 
been  well  anaesthetized.  The  operation  of  laryngeal  extirpation 
commences  with  an  incision  in  the  median  line  wdiich  s'lould 
begin  at  the  hyoid  bone,  and  be  continued  downwards  to  the 
upper  portion  of  the  trachea.  Through  this  longitudinal  cut, 
the  larynx  may  be  exposed  by  dissection,  and  the  entire  work  of 
removal  done;  other  operators  however  have  enlarged  the  oper- 
ative field  by  intersecting  the  vertical  cut  by  a  transverse  one. 
Or  to  the  longitudinal  cut,  two  transverse  ones  may  be  made,  so 
that  a  lateral  flap  is  formed  on  each  side.  The  median  longitu- 
dinal cut  has  been  found  sufficient  by  many  operators ;  3'et  should 
it  be  found  inadequate  as  the  work  proceeds,  then  such  sub- 
sidiary incisions  may  be  made,  as  the  conditions  found  may 
necessitate. 

If  the  surgeon  confines  himself  to  the  single  longitudinal  cut, 
this  must  penetrate  to  the  cartilaginous  structures,  when,  by 
means  of  the  blunt  dissector,  the  cutaneo-muscular  tissues  are  to 
be  reflected  laterally.     In  this  dissection  there  will  be  encountered 


EXTIRPATION    OF    THE    LAKYNX.  1089 

above,  the  laryngeal  arteries,  penetrating  the  hyo-thyroidean 
membrane;  and  below,  the  crico-thyroidean  arteries  which  per- 
forate the  crico-thyroidean  membrane.  In  each  case,  the  vessel 
is  to  be  doubly  ligated,  and  divided  between  the  ligatures.  By 
following  the  surface  of  the  thyroid  cartilage,  the  middle  cervical 
fascia  and  the  included  muscles  can  be  uplifted.  The  sterno- 
hyoid muscles  may  remain  unsevered;  but  thesterno-thyroid  and 
the  thyro-hyoid  muscles  must  be  severed  from  their  connection 
with  the  thyroid  cartilage.  In  these  soft  structures  are  contained 
lateral  lobules  of  the  thyroid  gland;  and  with  care  the  nutrient 
arteries  of  these  parts  need  not  be  disturbed. 

When  the  larynx  has  thus  been  separated  from  the  soft  parts 
and  exposed  fully  to  view,  then  the  removal  may  be  done  from 
above  downwards,  or  from  below  upwards;  and  each  mode  has 
its  advocates. 

After  exposing  to  view  the  larynx  and  upper  part  of  the 
trachea,  the  removal  from  below  upwards  commences  by  a  trans- 
verse cut  between  the  cricoid  and  thyroid  cartilages;  and  if  then 
the  cricoid  cartilage  be  found  sound,  it  may  be  left,  and  the 
thyroid  and  attached  arytenoid  cartilage  may  be  pulled  outwards, 
uplifted  and  separated  from  the  oesophagus,  and  tissues  to  which 
they  are  adherent  behind;  and  when  the  hyoid  bone  is  reached, 
the  structures  may  be  divided  just  below.  In  this  separation,  the 
superior  and  inferior  laryngeal  nerve  will  be  severed;  an  unim- 
portant sacrifice,  since  the  parts  which  these  nerves  innervate  are 
removed.  Should  any  vessels  be  met  in  the  detachment,  these 
should  be  carefully  ligated.  In  regard  to  the  epiglottis,  authority 
is  divided  respecting  its  removal,  or  retention  :  those  who  would 
preserve  it,  claim  that  it  would  prevent  the  entrance  of  foreign 
materials  into  the  artificial  larynx;  on  the  contrary,  Czerny  and 
Maas  found  that  if  it  was  retained,  it  fell  into  the  artificial  larynx, 
and  interfered  with  its  proper  action.  Wegner,  who  removed  the 
larynx,  preserved  the  epiglottis,  and  from  his  experience  he 
prefers  this  mode;  hence,  with  eminent  authority  for  and  against 
the  procedure,  it  is  probable  that  it  is  a  matter  of  little  import 
which  m.ethod  is  selected.  When  its  ablation,  complete  or  total, 
is  decided  on,  the  part  may  be  seized  v/ith  forceps  and  drawn 
into  the  upper  part  of  the  cut,  and  then  as  much  may  be  excised 
as  is  desired.  Should  it  be  suspected  that  the  epiglottis  is  affected 
with  malignant  disease,  it  should  be  wholly  extirpated,  and  even 
the  excision  may  encroach  on  the  base  of  the  tongue. 

In  whatever  way  the  work   be   done,  whether  from   below. 


100(>  KXTIRPATIOX    OF    THE    LARYNX. 

Upwards,  or  I'roiii  above  downwards,  it  will  be  well  to  open  the 
larynx  by  a.longitudinal  cut  in  front,  through  which  an  inspec- 
tion can  be  made  of  the  inner  surface ;  tlius  a  more  correct  notion 
can  be  obtained  of  tlie  isolation  or  diffusion  of  the  disease.  By 
this  means,  both  the  upper  and  lower  ends  can  be  examined,  and 
thus  the  excision  may  extend  as  far  as  may  be  required.  If  it  be 
found  that  the  cricoid  cartilage  is  sound,  it  may  be  left  in  its 
entirety:  or,  perhaps,  a  portion  of  it  may  be  spared,  and  thus  the 
support  for  the  vocal  prothesis  will  be  improved. 

A  troublesome  complication  may  exist  in  the  extension  of  the 
disease  to,  and  implication  of,  the  oesophagus;  and  in  such 
condition  it  becomes  necessary  to  extend  the  sphere  of  the  opera- 
tion, and  to  include  the  affected  portion  of  the  oesophagus.  Such 
removal  must  be  thorough,  since  to  leave  a  fragment  of  disease, 
however  small  this  might  he,  would  not  improve  the  patient's 
condition.  And  such  removal,  interfering  as  it  must  with 
normal  deglutition,  will  cast  an  additional  shadow  on  the  patient's 
future.  If  but  a  limited  portion  of  the  canal  be  implicated,  then 
it  might  be  possible  to  excise  a  section,  and  then  approximate 
and  effect  an  anastomosis  between  the  remaining  ends.  If  the 
disease  were  so  extensive  as  to  prevent  restoration  of  continuity, 
then  the  affected  part  must  be  removed,  and  alimentation  main- 
tained by  means  of  a  tube  introduced  into  the  distal  portion  of 
the  remaining  oesophagus. 

In  not  a  small  number  of  cases  observed,  the  oesophagus  has 
been  the  part  in  which  the  malignant  neoplasm  commenced; 
and  thence  extended  to  the  larynx.  If  such  a  case  be  early 
recognized,  it  might  be  possible  to  remove  the  disease  by  an 
exsection  of  the  oesophagus,  with  the  removal  of  a  limited  portion 
of  the  larynx ;  and  in  this  case,  if  the  excision  of  the  oesopliagus 
be  extensive,  then  it  would  probably  become  necessary  to  nourish 
the  patient  through  a  tube  retained  permanently  in  the  cervical 
opening. 

Cases  also  occur  in  which  the  disease,  commencing  in,  and 
extending  from  the  larynx,  spares  the  ossophagus,  but  attacks 
the  parts  situated  laterally.  When  the  disease  is  thus  situated, 
besides  laryngeal  ablation,  the  muscles  and  other  structures 
which  are  found  implicated  must  be  liberally  sacrificed. 

As  appears  from  what  has  been  stated,  there  is  but  little 
uniformity  in  the  local  development  of  laryngeal  cancer;  and 
the  more  favorite  sites  of  the  disease  are  indicated  in  tlie  follow- 
ing statistics  of  Ziemssen  and  others.     In  eighty-two  cases,  the 


EXTIRPATION    OF    THE   LARYNX.  1091 

disease  began  in  the  epiglottis  in  thirteen;  in  thirty-six,  it  was 
unilateral,  occurring  seventeen  times  on  the  right  side,  and  nine- 
teen times  on  the  left  side.  Of  thirty-seven  cases  seen  by  Fauvel, 
it  was  unilateral  in  all  the  cases  except  one;  and  in  nearly  all  the 
patients,  the  afifection  was  seated  on  the  left  side. 

The  limitation  of  the  disease  to  a  small  part  of  the  interior 
surface  of  the  larynx  has  led  to  thyreotomy,  in  which  the  carti- 
lage being  opened,  the  diseased  part  was  removed.  This  conserv- 
ative plan  has  usually  been  followed  by  recurrence;  and  hence, 
to  insure  against  a  return  of  the  disease,  there  should  be  a 
thorough  extirpation  of  the  affected  and  suspected  structures. 

When  the  affection  is  unilateral  in  site,  the  work  may  be 
limited  to  the  removal  of  one  side  of  the  larynx.  This  partial 
ablation  has  been  done  successfully  by  Billroth;  the  remaining 
vocal  chord  sufficed  for  the  function  of  voice;  and  thus  the 
necessity  of  an  artificial  larynx  is  dispensed  with.  The  caution 
here  is  proper,  that  there  should  not  be  too  much  economy  in 
the  work  of  the  knife,  lest  the  uneradicated  disease  may  reappear. 
Every  surgeon  in  the  review  of  his  operative  work  in  the  treat- 
ment of  malignant  disease,  has  cause  to  regret  such  economy. 
This  statement  is  painfully  supported  by  the  personal  experience 
of  the  author. 

After  thorough  excision  of  the  diseased  tissues  the  remaining 
surface  should  be  carefully  inspected  to  determine  whether  all 
traces  of  the  disease  have  been  removed;  and  if  this  has  been 
accomplished,  the  wounded  surface  should  be  sponged  with  a  six 
per  cent  solution  of  chloride  of  zinc. 

The  remaining  treatment  of  the  wound  is  a  subject  of  discus- 
sion among  operators;  as  closure  or  non-closure  of  the  cut-throat 
has  been  a  matter  of  contention  among  surgeons,  so  a  similar 
question  has  been  mooted  between  the  operators  of  laryngectomy. 
Schiiller  advocates  the  open  or  partially  open  treatment  of  the 
wound,  claiming  that,  thus  proceeding,  the  surgeon  is  better  able 
to  observe  the  progress  of  the  healing,  and  to  obviate  or  relieve 
any  intercurrent  disturbance.  If  the  wound  be  thus  treated,  the 
opposite  walls  of  the  opening  will  advance  towards  each  other  so 
that  soon  there  remains  a  hollow  canal,  incompletely  closed  in 
front;  and  this  closure  often  proceeds  so  rapidly,  that  it  becomes 
necessary  to  reopen,  and  retard  the  rapid  approach  of  the  opposite 
walls  towards  each  other.  In  case,  however,  lateral  flaps  are 
made,  then  partial  closure  should  be  made  by  means  of  one  or 
two  sutures,  which  pass  through  the  angles  of  the  flaps,  so  as  to 


1092  EXTIRPATION    OF    THE    LARYNX. 

fix  and  hold  them  in  place.  By  this  incomplete  closure,  there 
will  remain  an  intermediate  opening  sntticient  for  the  purpose 
just  mentioned.  It  should  be  stated  that  in  a  case  of  successful 
laryngectomy  done  by  Bottini,  he  pursued  the  opposite  plan:  he 
closed  the  wound  completely  by  sutures. 

If  only  a  small  opening  be  made  in  the  pharyngeal  or  oesoph- 
ageal wall,  this  should  be  closed. 

If  the  trachea  when  severed  were  not  fixed  in  some  way,  it 
would  descend  and  become  buried  and  closed  by  the  dermal 
structures;  to  prevent  this  descent,  the  lower  end  should  be 
securely  sutured  in  the  wound  so  that  it  will  remain  in  its  site, 
and  not  become  closed ;  and  to  insure  patency  of  the  trachea,  a 
canula  should  be  introduced  at  once,  and  allowed  to  remain  per- 
manently in  position. 

Another  important  part  of  the  operation  is  to  make  provision 
for  the  alimentation  of  the  patient;  and  this  is  done  by  introduc- 
ing a  tube  through  the  wound  which  has  opened  the  cesophagus, 
and  letting  this  reach  to  the  stomach  and  remain  permanently  in 
the  canal:  and  around  the  tube,  the  w^ound  can  be  packed  with 
aseptic  lint  or  gauze. 

The  tracheal  canula,  through  the  aid  of  a  tamponing  accom- 
paniment, or  other  occlusive  means,  should  so  fill  the  trachea 
that  no  excreta  can  enter  it;  and  to  insure  against  such  descent 
of  matter,  the  wound  should  be  redressed  daily.  In  this  dressing, 
the  surface  of  the  wound  should  be  cleansed  with  alcoholized 
water;  and  also  the  mouth  should,  at  short  intervals;  be  rinsed 
with  camphor  water,  or  mint  water. 

Through  the  oesophageal  tube,  limited  amounts  of  liquid 
nutrient  material  must  be  introduced  to  the  stomach ;  such  nutri- 
ment may  consist  of  soups,  milk,  wine-whey,  milk  with  brandy, 
and  other  articles  of  food  of  which  the  liquid  character  will  per- 
mit of  introduction  through  the  tube.  Nutrition  by  the  rectum 
may  also  be  resorted  to;  and  for  this  purpose,  pancreatinized 
milk  may  be  employed. 

If  the  lesion  of  the  pharynx  or  cesophagus  be  a  small  one,  so 
that  it  may  close  soon,  then  the  tube  for  transmission  of  nutri- 
ment may  be  passed  through  the  mouth,  and  the  patient  thus 
fed;  thus  proceeding,  the  healing  may  advance  more  rapidly. 
After  these  operations,  patients  soon  learn  to  swallow :  difficulties 
which  were  great  at  first,  are  gradually  overcome.  The  base  of 
the  tongue  is  drawn  towards  the  ])osterior  wall  of  tlie  pharynx, 
so  that  the  food  is  carried  through   the  faucial  isthmus  to  its 


EXTIRPATION    OF    THE    LARYNX.  1098 

proper  channel  below.  Long  ago,  the  physiologist  Longet  deter- 
mined by  vivisective  trial,  that  the  dog  deprived  of  the  epiglottis, 
soon  learns  to  swallow  food;  and  this  fact  has  been  corroborated 
in  the  human  subject,  in  whom,  from  ulcerative  disease,  the 
epiglottis  has  been  lost:  the  subject  soon  learned  to  swallow, 
without  strangling. 

In  the  case  operated  on  by  Billroth,  the  patient  was  able  to 
swallow  liquids  after  one  week  ;  and  after  three  weeks  he  could 
swallow  solids.  The  patient  of  Foulis  swallowed  fluids  after  five 
days;  and  that  of  Bottini,  after  a  short  time.  From  the  cases 
observed,  it  is  clear  that  the  troubles  apprehended  from  dyspha- 
gia after  laryngectomy  have  fortunately  not  been  verified. 

Total  extirpation  of  the  larjmx  in  the  removal  of  the  vocal 
chords  necessarily  deprives  the  patient  both  of  voice  and  articu- 
lated speech:  he  becomes  dumb;  and  thereby,  is  shut  off  from  an 
important  part  of  the  enjoyment  of  life.  In  the  treatment  of 
criminals,  condemnation  to  silence  is  one  of  the  severest  punish- 
ments. Thanks,  however,  to  surgical  ingenuity,  the  operator  who 
takes  from  the  patient  his  natural  organ  of  voice,  is  able  to  give 
him,  instead,  an  artificial  one:  the  deft  hand  of  Vincent  Czerny, 
who  gave  surgical  art  this  novel  operation,  gave,  also,  the  yet 
more  novel  device  of  the  artificial  larynx.  In  his  operations  on 
the  dog,  Czerny  introduced  into  the  trachea  a  canula,  in  which 
there  was  placed  a  vibrating  metallic  tongue ;  and  from  this  ger- 
minal device,  of  which  the  action  was  first  verified  in  the  dog, 
sprang  a  more  complex  appliance,  designed  by  Gussenbauer  and 
made  by  a  mechanician  in  Vienna,  for  use  in  a  man  from  whom 
Billroth  had  extirpated  the  larynx ;  and  this  was  successful  in  ena- 
bling the  man  to  talk  in  articulate  speech.  In  language,  the  single 
function  of  the  larynx  is  the  development  of  sound;  this  sound 
is  converted  into  articulated  words  composed  of  single  or  multi- 
ple elementary  sounds,  by  means  of  movements  made  by  the 
pharynx,  soft  palate,  nostrils,  inner  walls  of  the  cheeks,  lips  and 
tongue:  the  last  instrument,  though  it  has  given  its  name  to 
language,  performs  but  a  minor  part  in  lingual  function,  since  it 
really  shapes  but  three  elementary  sounds.  For  the  restoration 
of  articulate  speech  after  the  removal  of  the  larynx,  it  is  only 
necessary  to  restore  the  function  of  the  latter  by  introducing  in 
its  place  a  cord,  thread  or  metallic  tongue  so  fixed  as  to  vibrate 
in  the  current  of  expired  air:  and,  what  is  remarkable  and  diffi- 
cult of  explanation,  the  coinage  of  words,  though  somewhat 
uncouth,  can  be  made  bv  a  current  of  insoired  air.     The  artificial 


1094 


EXTIRPATION    OP    THE    LARYNX. 


larynx  has  for  its  office  the  generation  of  sound:  its  possessor 
being  given  a  sound,  coins  the  hitter  into  the  infinitude  of  forms 
which  compose  speech.  A  number  of  such  devices  have  been 
contrived ;  that  of  Gussenbauer  was  the  first  that  was  used  in 


man. 


The  artificial  larynx  of  Gussenbauer,  shown  in  Figure  107,  is 
composed  of  the  following  parts:  a  tracheal  portion,  a  laryngeal 
portion,  and  the  apparatus  for  phonation.  Tlie  first  and  second 
parts  are  made  of  hard  rubber,  while  the  vocal  portion  is  made  of 
German  silver.  The  tracheal  portion  is  a  long  curved  part,  in 
shape  similar  to  the  canula  used  in  tracheotomy;  and  this  is  first 


Figure  107.     Sliowing  the    inferior    of   Gussenbauer's  artificial    larynx. 
(From  Schiiller.) 

put  in  place,  when  the  laryngeal  part  is  next  introduced  into  the 
wound,  corresponding  to  the  site  of  the  larynx;  and  then  through 
an  opening  in  the  latter,  the  part  for  phonation  is  placed,  and  is 
similar  to  a  drawer  which  can  be  moved  inwards  or  outwards; 
and  this  contains  a  metallic  tongue  which  vibrates  in  the  current 
of  passing  air.  This  phonic  section  communicates  above  and 
below  with  the  laryngeal  and  tracheal  portions;  it  also  opens 
externally;  and  hence  when  the  instrument  is  in  use,  this  latter 
outlet  must  be  closed.  To  the  laryngeal  portion  there  is  attached 
above  and  in  front  a  movable  valve,  wliich  is  designed  to  act  tlie 
part  of  an  epiglottis.     This  portion  was  afterwards  found  unnec- 


EXTIRPATION    OP    THE    LARYNX.  1095 

essary,  and  left  off:  since  in  swallowing,  the  base  of  the  tongue 
moving  backwards  can  dispense  with  an  epiglottis.  •    - 

Hueter  adapted  an  artificial  larynx  to  a  man  who  in  attempt- 
ing self-destruction, excised  a  portion  of  the  larynx;  this  consisted 
of  a  single  canula,  which  was  so  bent  as  to  be  in  bayonet  form. 
The  tracheal  portion  was  larger  and  narrower  than  the  upper  or 
laryngeal  portion;  and  in  the  latter  there  was  a  simple  vibrating 
tongue.  At  the  junction  of  the  two  portions,  the  canula  had  an 
opening  through  which  passed  the  inspired  and  expired  air: 
and,  when  the  subject  desired  to  talk,  this  opening  was  shut  so 
that  the  expired  air  passed  upwards  and  caused  a  vocal  tone, 
which  could  be  shaped  into  articulate  speech. 

In  the  patient  from  which  Foulis,  of  Glasgow,  extirpated  the 
larynx,  he  simplified  the  matter  by  using  only  a  tracheal  canula, 
in  which  he  inserted  a  vibrating  tongue;  this  tongue,  drawer- 
like, could  be  dravs^n  in  and  out.  In  this  device,  the  vibrating 
tongue  was  so  placed  that  the  expired  air  came  chiefly  in  contact 
with  the  free  end  of  the  tongue.  Foulis  tried  different  materials, 
in  the  construction  of  the  tongue,  such  as  vulcanite,  iron,  horn, 
reed  and  metals.  The  tongue  compounded  of  copper  and  silver 
he  found  to  be  the  one  which  yielded  the  loudest  sound;  yet 
those  from  non-metallic  material,  though  weaker,  gave  a  sound 
most  nearly  like  that  of  the  human  voice. 

The  construction  of  the  artificial  larynx  in  the  different 
forms  in  which  it  has  been  made,  has  afforded  ample  opportu- 
nity for  the  exercise  of  mechanical  ingenuity;  still,  some  difficul- 
ties have  been  encountered  in  the  work,  which  can  scarcely  be 
said  to  have  been  wholly  overcome;  the  one  is  the  length  of  the 
laryngeal  portion,  which,  when  it  reaches  too  high  upwards, 
interferes  with  the  backward  movement  of  the  tongue  in  deglu- 
tition: and  the  other  is  that  mucus  and  foreign  matter  tend  to 
lodge  on  the  sounding  tongue,  and  to  interfere  with  its  proper 
action.  According  to  the  writer's  judgment,  in  the  simple  device 
of  Hueter,  and  the  somewhat  more  complex  one  of  Foulis,  these 
difficulties  have  been  most  successfully  met:  yet  after  the  best 
that  has  been  done,  when  compared  with  Nature's  simple  model, 
the  effort  of  Art  has  but  slight  cause  for  exultation. 


CHAPTER    XXXIV 


VESSELS   OF    THE   NECK. 


When  the  neck  is  viewed  in  respect  to  its  vascularity,  it  is 
found  that  all  the  vessels  of  importance  lie  in  tlie  anterior  region ; 
those  lying  behind  are  of  minor  calibre. 

The  vessels  in  front  may  be  divided  into  two  classes;  those  of 
intercommunication  between  the  trunk  and  the  head,  and  those 
connecting  tlie  upper  extremity  and  the  trunk;  the  former  is 
the  carotid  artery,  and  on  its  outer  side,  lies  its  great  satellite,  the 
internal  jugular  vein. 

The  term  carotid,  according  to  Rufus  of  Ephesus,  is  of  Greek 
origin,  and  refers  to  the  fact  known  to  the  ancients  that  when 
the  carotids  are  compressed,  such  pressure  induces  coma. 

AVhen  the  primitive  carotids  are  compared  with  each  other, 
the  left  is  somewhat  longer  than  the  right,  and  it  lies  deeper, 
and,  as  a  rule,  it  is  smaller  in  diameter.  In  their  lower  portion, 
these  vessels  lie  about  three-fourths  of  an  inch  behind  the  clavi- 
cle, the  left  carotid  being  somewhat  deeper.  While  the  left 
carotid  lies  wholly  on  the  left  side  of  the  trachea,  the  right  one 
encroaches  on  the  right  side  of  the  trachea,  for  a  short  distance. 

Cutaneous  landmarks,  which  serve  as  guides  for  finding  the 
arteries,  are  the  following:  on  the  right  side,  a  line,  drawn 
from  the  space  or  sulcus  between  the  ramus  of  the  lower  jaw 
and  the  mastoid  process  to  the  inner  end  of  the  clavicle,  lies 
over  the  right  carotid.  But  for  the  left  carotid,  let  the  line, 
starting  from  the  similar  space  on  the  left  side,  reach  down  to  the 
interspace  between  the  sterno-mastoid  and  cleido-mastoid  mus- 
cles, at  their  insertion:  that  is,  the  left  vessel  lies  further  from  the 
median  line  of  the  body  than  does  the  right  vessel.  Allan 
Burns  remarks  that,  as  a  rare  anomaly,  the  carotid  artery  may 
bifurcate  as  low  in  the  neck  as  the  sixth  cervical  vertebra;  in 
such  a  case,  the  surgeon,  instead  of  finding  one,  would  find  two 
trunks.  The  usual  site  of  bifurcation  is  on  a  level  with  the 
upper  border  of  the  thyroid  cartilage.  At  the  point  of  division 
( 1096 ) 


VESSELS    OF    THE    NECK.  1097 

the  primitive  carotid  presents  a  fusiform  enlargement:  an 
enlargement  which  has  been  mistaken  for  an  incij)ient  aneurism. 
The  author  was  once  consulted  by  a  surgeon  who  was  laboring 
under  such  apprehension.  In  this  case,  as  in  similar  ones 
observed,  there  was  tenderness,  amounting  almost  to  constant 
pain;  yet  no  further  enlargement  occurred:  nor  did  the  incon- 
venience thus  arising  ever  exceed  the  limits  mentioned. 

At  their  commencement  the  carotids  are  covered  b}'  the  sterno- 
hyoid, sterno-thyroid  and  the  sterno-cleido  mastoid  muscles  :  also 
by  the  subclavian  veins;  but  above,  near  the  bifurcation,  the 
artery  is  covered  only  by  the  skin  ancLinner  margin  of  the  sterno- 
cleido-mastoid  muscle.  The  left  carotid  lies  near  the  oesophagus, 
while  the  right  one  is  more  remote  from  this  passage;  and  both 
vessels  lie  on  the  inner  border  of  the  internal  jugular  vein, 
which  swells  during  expiration,  and  overlaps  the  carotid,  espe- 
cially in  the  lower  part  of  its  course.  The  carotids  lie  near  the 
anterior  tubercles  of  the  transverse  processes  of  the  cervical 
vertebrae;  and  the  tubercle  of  the  sixth  vertebra  is  so  prominent 
and  distinguishable  that  it  serves  as  a  guide  to  find  the  vessel, 
and  thence  it  has  been  named  by  Chassaignac  the  carotid  tuber- 
cle. The  inferior  thyroid  artery  in  its  ascent  lies  behind  the 
carotid  arter3^ 

The  artery  has  an  important  relation  with  the  omo-hyoid 
muscle,  which  crosses  it  in  its  descent  downwards  and  outwards; 
thus  the  vessel  is  mapped  off  into  a  supra-omo-hyoid  and  an 
infra-omo-hyoid  portion.  From  the  observation  of  a  great  num- 
ber of  ligations  of  the  vessel,  it  appears  that  when  the  work  is 
done  above  the  muscle,  there  are  more  recoveries  than  deaths ; 
but  when  done  on  the  infra-omo-hyoid  portion,  the  case  is 
reversed,  the  deaths  exceed  the  recoveries. 

Besides  the  cutaneous  landmark  before  given  for  incising  to 
the  vessel,  another  guide  is  the  inner  margin  of  the  sterno- 
cleido-mastoid.  It  must  be  remembered  that  these  guides  are 
not  infallible  when  the  head  is  inclined  far  backwards:  for  then 
the  vessels  lying  on  the  convex  surface  of  the  vertebral  column 
slide  and  shift  their  positions  laterally.  And  this  accounts  for 
the  frequent  failure  of  the  suicide's  knife  to  reach  the  vessels:  for 
with  the  head  turned  far  backwards,  as  the  writer  has  known,  a 
frightful  yet  unimportant  cut  may  be  made  in  which  the  air- 
passage  is  but  slightly  opened.  In  his  wild  and  determined 
attempt  to  fatally  cut  his  throat,  the  suicide  may  not  only  be 
prevented  by  the  retreating  vessels,  but  the  frightful  sound  of  the 
70 


109S  VESSELS    OP    THE    NECK. 

air  escaping  from  the  opened  windpipe  makes  liim  believe  that 
he  has  aceompHslied  his  work,  when  in  reality  he  has  only 
but  slightly  wounded  himself. 

In  many  emergencies  in  which  hiEmorrhage  occurs  about  the 
face,  or  in  the  mouth  or  throat,  an  arrest  of  the  bleeding  is 
accomplished  by  compression  of  the  corresponding  primitive 
carotid.  By  such  compression  the  loss  of  blood  can  be  tempora- 
rily controlled,  until  the  bleeding  vessel  can  be  tied.  The  site 
advised  for  compression  is  over  the  carotid  tubercle,  in  the  lower 
part  of  the  neck ;  yet  from  the  writer's  experience,  he  has  found 
that  such  compression  can  be  made  ujuch  more  effectively  if  done 
higher  up;  that  is,  alongside  of  the  larynx:  for  here  the  vessel 
can  easily  be  felt;  and  if  the  acting  fingers  be  directed  from 
without  inwards,  the  carotid  in  the  ordinary  subject  can  be  easily 
fixed,  and  held  alongside  of  the  air-passage.  By  such  com- 
pression the  writer  has  controlled  bleeding  from  some  part  above, 
until  some  means  of  permanently  controlling  it  could  be  resorted 
to.  In  case  of  violent  epistaxis,  the  bleeding  has  thus  been 
retarded,  so  that  a  clot  could  form  at  the  bleeding  point,  and  the 
h?emorrhage  thus  be  controlled;  or  if  the  site  of  bleeding  l)e  an 
accessible  one  within  the  mouth,  or  externally,  on  the  face,  then 
such  compression  can  so  lessen  the  escape  of  blood  tluit  the  j^oint 
can  be  seen  and  secured  by  ligature,  or  other  heemostatic  means. 

Affections  of  the  Carotid  Artery. — The  carotid  artery  is  the  sub- 
ject of  disease  or  injury;  and  this  agency  may  be  indirect  or  direct 
in  its  action. 

As  an  example  of  disease  originating  indirectly,  may  be  cited 
that  arising  from  an  abscess  in  proximity  to  the  carotid,  which 
through  its  closeness  or  contact  with  the  vessel,  may  attack  and 
disintegrate  its  walls.  The  starting  i)oint  of  such  abscess  may  be  a 
diseased  gland,  which,  enlarging,  presses  on  the  vessel,  and,  finally, 
the  latter  may  be  involved  in  the  suppurative  disintegration  of 
the  gland.  The  true  nature  of  such  a  case  may  not  be  sus]3ected, 
and  grave  error  arise  from  too  hasty  action  in  the  treatment. 
This  occurred  in  the  practice  of  a  famous  English  surgeon,  who, 
on  making  a  visit  to  his  hospital  one  morning,  was  shown  a 
patient  with  a  swelling  on  the  neck,  which  he  mistook  for  an 
ordinary  abscess,  which,  according  to  rule,  the  case  should  have 
been ;  but  this  case,  unfortunately,  proved  to  be  an  exception,  as 
was  painfully  verified  by  the  surgeon,  who,  with  more  precipita- 
tion than  reflection,  plunged  his  lance  into  the  tumor,  and  his 
wound  was  followed  by  a  haemorrhage  which  ended  fatally. 


AFFECTIONS    OF    THE    CAROTID    ARTERY.  1099 

In  the  plan  often  pursued  of  curetting  the  suppurating  gland, 
there  is  peril  of  inadvertently  injuring  the  cervical  vessels.  The 
curette,  however,  endangers  the  wall  of  the  vein  more  than  that 
of  the  artery,  since  from  the  more  quiescent  condition  of  the  vein, 
adherence  to  it  is  facilitated;  and,  besides,  the  wall  of  the  vein 
being  thinner  and  weaker,  it  can  more  readily  be  opened. 

Besides  joeril  from  su^Dpurative  action,  the  walls  of  the  carotid 
may  become  implicated  in  erosive  or  ulcerative  disintegration 
seated  in  structures  adjacent,  and  the  vessel  thus  opened.  As 
such  erosion  would  be  open  to  view,  the  watchful  surgeon  might 
intervene  with  his  ligature,  before  the  wall  was  perforated. 

The  anterior  cervical  structures  are  sometimes  the  seat  of 
general  phlegmonous  inflammation  in  which  there  is  a  rapid 
breaking  down  of  the  tissues,  and  acrid  pus  appears  in  profusion, 
in  which  the  vessels  lie,  and  their  walls  are  exposed  to  its  corro- 
sive action;  and  the  final  result  may  be  a  perforation  of  the  vas- 
cular wall,  with  profuse  subcutaneous  haemorrhage.  The  writer 
has  known  the  coats  of  the  internal  jugular  vein  to  be  thus 
opened;  but  the  thicker  wall  of  the  carotid,  and  the  early  incision 
by  the  surgeon  of  the  sloughing  parts,  would  guard  against 
arterial  haemorrhage. 

The  more  common  injury  of  the  carotid  is  that  of  traumatic 
nature,  which  may  be  a  contusion,  or  the  wound  may  be  caused 
by  a  cutting  blade,  a  gunshot  missile,  a  pointed  instrument,  as  a 
needle,  arrow,  lance,  or  other  penetrating  agency  that  cuts  or 
tears  a  way  into  the  tissues. 

A  severe  contusion  of  the  anterior  cervical  structures  may 
involve  and  so  injure  the  carotid  artery  that  the  vessel  may  rup- 
ture; and  such  rupture  might  be  confined  to  a  miniature  cleft, 
through  which  blood  could  merely  escape;  or  a  large  opening 
might  occur  through  which  fatal  haemorrhage  could  quickly 
ensue. 

The  incised  wound  of  the  carotid  may  vary  from  a  minute 
prick  to  a  complete  division  of  the  vessel;  and  the  gravity  of  the 
case  will  be  proportionate  to  the  wound. 

A  wound  in  which  the  wall  is  simply  pricked,  as  by  a  needle, 
or  a  small  blade  of  a  knife,  may  bleed  rapidly  for  a  short  time, 
and  then  cease  through  the  formation  of  clot,  either  in  the 
opened  wall,  or  in  the  canal-like  wound  made  by  the  injuring 
agent  in  reaching  the  vessel.  The  peril  in  such  a  case  is  that 
the  bleeding  is  perhaps  only  temporarily  arrested,  and  may  soon 
recur;  or  if  this  does  not  ensue,  a  false  aneurism  mny  originate, 


IIUU  VKsiSELS    OF    THE    NECK. 

at  tlje  site  of  tlie  wound.  If  it  be  evident  that  the  wound  is  only 
a  :?light  one,  tlie  approi>riate  treatment  would  be  to  put  the  patient 
immediately  at  rest,  and  then  place  an  adhesive  compress  on  the 
wound,  and  retain  this  in  place  by  means  of  a  circular  bandage, 
or  adhesive  straps,  around  the  neck.  A  slight  wound  might  thus 
be  successfully  treated.  If  the  wound  were  a  larger  one,  the 
hcemorrhage  would  be  profuse,  and  would  .soon  end  life,  unless 
the  wound  had  some  peculiarities  of  form  which  would  aid  in  tiie 
formation  of  a  clot,  that  might  give  the  victim  a  temporary 
respite;  for  example,  if  the  track  of  the  wound  were  sinuous,  or 
its  walls  uneven  through  retraction  of  severed  muscular  .struc- 
ture, then  clotting  blood  might  occlude  the  wound.  The  direc- 
tion of  the  wound  might  cooperate  in  this  coagulation;  for 
instance,  were  thp  direction  of  the  canal  the  opposite  of  that  of 
the  blood-current,  this  would  retard  the  exit  of  blood,  and  favor 
occlusion  by  a  thrombus.  In  such  a  patient,  it  would  be  impru- 
dent to  expect  that  the  bleeding  would  thus  be  permanently 
arrested,  and  that  clo.sure  of  the  wounded  wall  would  ensue  with- 
out operative  aid  ;  in  such  a  case,  ligation  should  be  resorted  to 
as  the  proper  safeguard  against  an  early  return  of  the  haemor- 
rhage. 

If  the  wound  traverses  the  tissues  for  some  distance  before  it 
reaches  the  carotid,  though  it  make  a  large  wound  in  the  wall, 
or  wholly  sever  the  vessel,  yet,  if  compression  were  prof)eriy 
made,  it  would  be  possible  to  save  the  patient  by  immediate  liga- 
tion, as  the  following  famous  case  demonstrated:  a  girl  was 
stabbed  with  a  knife,  in  the  upper  part  of  the  neck;  with  a  large 
stream  of  blood  gushing  from  the  wound,  she  reached  the  estab- 
lishment of  a  druggist  near  by,  who  with  fortunate  presence  of 
mind,  thrust  his  finger  into  the  wound  and  arrested  the  external 
bleeding  until  the  surgeon  Michon,  who  was  summoned,  arrived. 
Miclion  found  the  patient  bloodless  and  almost  dead;  the  soft 
parts  around  the  wound  were  greatly  swollen  by  the  passage  of 
blood  into  them  from  the  wound,  that  was  only  closed  externally. 
The  surgeon  introduced  his  finger  through  the  wound,  and  find- 
ing the  artery  entirely  severed,  he  inserted  the  finger  into  the 
cardiac  end;  with  the  other  hand  he  cut  down  and  exposed  the 
distal  end,  which  being  tied,  he  proceeded  to  ligate  the  proximal 
one.     By  this  prompt  work,  the  life  of  the  girl  was  saved. 

In  such  extensive  wound,  both  ends  of  the  carotid  artery  must 
be  tied:  for  if  the  cardiac  end  alone  were  tied,  then  through  the 
intercommunicating  circle  at  the  base  of  the  brain  and  through 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1101 

the  numerous  anastomoses  between  the  right  and  left  external 
carotids,  blood  can  soon  reach,  and  escape  freely  from  the  distal 
end.  Though  cases  have  been  reported  in  which  ligation  alone 
of  the  proximal  end  has  controlled  the  hgemorrhage,  yet  bleeding 
has  so  often  arisen  from  single  ligation,  that  in  case  of  a  large 
wound,  or  the  total  division  of  the  carotid,  the  prudent  surgeon 
will  tie  both  ends. 

Ligation  of  the  Primitive  Carotid. — The  carotid  may  be  tied  as 
a  preliminary  to  operative  work  on  structures  in  which  the  trunk 
or  some  of  its  branches  will  be  wounded.  Thus,  in  the  removal 
of  growths  within  the  throat,  or  the  infra-maxillary  region  of  the 
neck,  ligation  of  the  primitive  or  external  carotid  is  sometimes 
called  for.  Again,  when  the  tumor  lies  lower  down,  and  by 
pressure  has  w^eakened  the  arterial  walls,  ligation  is  indicated. 
Also,  in  those  cases  in  which  the  growth  has  reached,  infiltrated, 
and  incorporated  the  arterial  wall  in  itself:  in  such  condition,  the 
vessel  should  be  ligated  in  its  sound  portion,  and  the  diseased 
part,  along  with  the  growth,  being  removed,  the  distal  end  should 
be  tied  where  it  is  intact. 

The  malignant  tumor  is  sometimes  so  situated  that  in  its 
radical  extirpation,  a  portion  of  the  carotid  artery  is  left  bare, 
and  cannot  be  covered  by  any  plastic  shift,  in  the  effort  to  close 
the  wound.  For  example,  there  fell  under  the  writer's  observa- 
tion an  operation  in  a  Parisian  hospital,  in  which  a  large  benign 
tumor  was  removed  from  the  anterior  cervical  region,  in  which 
the  destruction  of  parts  was  so  extensive  that  the  carotid  artery 
was  left  exposed  for  some  distance.  The  operator  was  in  doubt 
whether  he  should  ligate,  but  decided  not  to  do  so.  A  few  days 
afterwards,  the  exposed  part  of  the  carotid  opened,  and  a  fatal 
bleeding  took  place:  and  in  a  clinical  lecture  on  the  case,  the 
operator  candidly  acknowledged  his  error,  with  keen  regret  that 
he  had  not  tied  the  vessel  at  the  time  of  the  operation. 

In  the  event  of  the  internal  carotid  beiug  opened  in  an 
operation  in  the  pharyngeal  region,  the  corresiDonding  primitive 
carotid  should  be  tied;  and  should  bleeding  still  continue  from 
the  distal  open  end,  through  refluent  blood  which  has  reached 
the  wound  through  the  circle  of  Willis,  then  if  death  be  impend- 
ing through  loss  of  blood,  the  surgeon  would  be  justified  in  tying 
the  opposite  primitive  carotid,  as  the  writer  did  in  a  case  which 
hereafter  shall  receive  mention. 

The  primitive  carotid  is  the  occasional  site  of  aneurism.  This 
is  an  infrequent  occurrence,  as  appears  from  the  figures  of  Crisp, 


1102  VESSELS   OF    THE    NECK. 

who  lias  collected  a  list  of  five  liundred  and  fifty-oiie  aneurisms, 
of  which  only  twenty-five  were  situated  in  the  primitive  carotid; 
that  is,  it  occurred  one  time  in  thirty  cases.  Of  these  twenty-five 
cases,  thirteen  occurred  in  women,  in  whom  such  aneurism 
appears  often er  than  in  men;  wliile  in  other  regions,  aneurism 
occurs  oftener  in  men. 

The  most  usual  cause  of  aneurism,  here  as  elsewhere,  is 
atheromatous  change  in  the  arterial  walls;  it  has  arisen  excep- 
tionally, from  some  violent  expiratory  effort,  as  vomiting.  It  has 
been  seen  in  the  infant,  though,  as  a  rule,  it  only  occurs  in 
mature  adult  life.  As  to  the  part  of  the  carotid  which  is  oftenest 
the  site,  authorities  disagree;  Burns  and  others  place  the  more 
common  site  near  the  bifurcation,  while  Robert  says  the  inferior 
portion  of  the  vessel  is  the  more  usual  site.  The  upper  portion 
is  probably  the  most  common  seat  of  aneurism ;  and  this  is 
dependent  on  anatomical  conditions,  viz.,  the  bifurcation  there, 
and  the  attenuated  stratum  of  overlying  structures.  Almost  the 
entirety  of  the  primitive  carotid  is  pressed  on  by  the  sterno-cleido- 
mastoid  muscle;  but  the  upper  fifth  is  nearl}^  free  from  muscular 
pressure;  and  on  this  account,  the  artery  can  expand  more  freely. 
And  this  takes  place  especially  in  expiratory  efforts,  as  in  cough- 
ing, when  the  expansion  of  both  the  artery  and  vein  is  visible 
to  the  eye;  and  under  such  circumstances,  it  is  rather  to  be 
wondered  at,  that  dilatation  or  rupture  of  the  vessel  is  not  a  more 
common  event. 

The  aneurismal  tumor  is,  at  first,  a  small  tumor,  passing,  for 
a  time,  unobserved  b}'^  the  patient;  finally,  its  enlarged  volume 
is  not  only  visible,  but,  by  its  pressure,  it  causes  inconvenience, 
and  even  severe  pain.  This  trouble  arises  from  compression  of 
nerves  which  lie  adjacent  to  the  growth:  also,  from  disturbance 
of  the  circulation  in  the  head.  When  the  tumor  is  low  on  the 
neck,  by  peripheral  extension  it  may  disturb  the  function  of  the 
pneumogastric,  the  inferior  laryngeal  nerve,  the  phrenic  and  the 
symi:>athetic  nerves;  and,  thence,  parts  remote  from  the  tumor,  as 
the  lungs,  diaphragm,  heart  and  laryngeal  muscles,  may  act 
irregularly.  Also,  through  the  sympathetic,  the  pupil  may  be 
caused  to  dilate  or  contract.  On  the  left  side,  the  tumor  may 
encroach  on  the  thoracic  duct,  and  thus  prevent  the  evacuation 
of  the  lymph  and  chyle  into  the  venous  system,  which  occurs 
near  the  seventh  cervical  vertebra.  The  tumor  can  also  com- 
press and  deform  the  oesophagus  and  tracheal  canal.  The  patient 
is  often  disturbed  by  the  movement  of  the  tumor  and  the  blowing 
sound,  which  usually  is  present  in  it. 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1103 

Sliould  the  aneurism  be  situated  higher  up,  then  the  functional 
disturbances  enumerated  will  be  present;  that  from  the  pulsa- 
tion and  blowing  sound  will  be  yet  greater,  and  the  power  to 
utter  vocal  sounds  may  be  quite  lost.  There  is  often  congestion 
of  the  face  on  the  side  of  the  aneurism  due  to  the  tumor  inter- 
rupting the  return  of  the  blood  from  the  head.  Vertigo,  dizziness 
and  ringing  of  the  ears  are  sometimes  present. 

AVhen  seated  high  up,  the  tumor  may  encroach  on  the  super- 
ficial cervical  plexus,  and  cause  pain  that  radiates  along  the 
nerves  which  arise  from  this  plexus;  thus  pain  in  the  pinna 
occipital  region,  and,  also,  in  the  acromial  and  clavicular  regions 
may  arise.  Not  unfi^equently,  a  troublesome  cough  is  present 
from  irritation  of  the  superior  laryngeal  nerve. 

A  very  troublesome  result  of  carotid  aneurism  often  seen  is 
difficulty  of  breathing,  arising  from  pressure  on  the  windpipe, 
by  which  the  latter's  calibre  is  narrowed ;  and  this  narrowing  is 
augmented,  or  mainlj'-  produced,  through  cedematous  swelling  of 
the  mucous  lining  of  the  air-canal.  This  stenosis  increasing  may 
finally  fatally  suffocate  the  patient. 

Carotid  aneurism  may  be  slow  in  its  development;  or  having 
grown,  for  a  time,  slowly,  it  maj^  suddenly  begin  to  increase  in 
volume,  and  soon  attain  large  proportions. 

The  diagnosis  of  the  carotid  aneurism  has  sometimes  been  a 
matter  of  much  embarrassment.  For  example,  if  it  be  in  the 
commencement  of  the  vessel,  it  is  difiicult  to  decide  whether  the 
tumor  maybe  of  aortic,  innominate,  subclavian  or  carotid  origin; 
and  sometimes  the  true  nature  of  such  cases  has  only  been  deter- 
mined through  necropsy,  in  which  the  exact  site  of  the  tumor  was 
discovered. 

The  greatest  difficulty  in  diagnosis  has  arisen  in  case  of 
abscess,  lipoma,  lymphoma,  encephaloid  growth  and  other 
neoplasm  situated  on,  or  adjacent  to,  the  carotid.  The  proximity 
of  such  tumor  to  the  vessel  has  permitted  the  pulsatile  motions 
of  the  latter  to  be  imparted  to  the  tumor;  and  besides  these 
movements,  the  pressure  of  the  tumor  on  the  vessel  may  alter  the 
form  of  the  latter  and  thereby  cause  a  sound  very  similar  to  that 
arising  in  the  aneurismal  tumor.  A  condition  in  which  sounds 
and  movements  resembling  those  of  the  aneurism  are  present, 
exists  in  the  vascular  encephaloid  growth ;  yet  this  tumor,  from 
the  writers  observation  and  experience,  rarely  develops  on  the 
neck;  its  usual  site  is  on  the  extremities.  The  differentiating 
means  by  which  the  ordinary  tumor  can  be  distinguished  from 


1104  VESSELS   OF    TIIK    NECK. 

the  aneurism  ure  iii;ij)|)licable  to  the  vascular  encephaloid. 
Perhaps  the  best  distinctive  characteristic  by  which  tliis  ence})h- 
aloid  growth  (Hffers  from  tlie  aneurism  is  in  its  form;  it  usually 
is  elongated  in  the  direction  of  the  longitudinal  axis  of  the  part 
on  which  it  is  situated;  it  has  connections  with  the  skin  which 
do  not  exist  in  the  aneurism;  and  its  volume  is  less  reducible  by 
compression  than  that  of  the  aneurism. 

In  case  of  the  solid  tumor  which  rests  on  the  artery  and 
receives  the  jnilsatile  movements  of  the  latter,  this  movement 
may  be  made  to  disa{)pear  through  lateral  displacement  of  the 
growth;  such  displacement  is  Cdnimonly  easily  made,  and  tlius 
the  true  character  of  the  tumor  is  decided.  Occasionally, 
however,  the  intimate  anatomical  connection  is  such  that  the 
two  cannot  be  separated;  and  in  this  condition  the  tumor  must 
move  synchronously  with  the  diastolic  movement  of  the  artery; 
and  it  continues  to  do  so,  even  though  the  growth  be  consider- 
ably moved  from  its  normal  site.  This  oftenest  occurs  wlien 
the  growth  is  of  glandular  origin,  since  the  gland,  whence  an 
adenoma  arises,  often  rests  on  the  sheath  of  the  vessel  and,  in 
developing,  forms  attachments  to  tiie  sheath.  And  if  the  tumor 
be  malignant  in  character,  it  often  penetrates  the  arterial  wall ; 
and  in  this  case  it  participates  in  the  movements  of  the  vessel. 
In  all  such  cases,  the  tumor  would  be  but  slightly  compressible; 
and  it  would  be  harder  than  an  anoui'ism.  xVnd  should  the 
evidence  from  these  sources  not  clear  u[)  the  diagnostic  obscurity, 
as  last  resort,  the  hypodermic  syringe  may  be  forced  deeply  into 
the  tumor,  and  thus  its  neoplastic  or  aneurismal  character  will 
be  determined.  The  hollow  needle  used  for  this  work  should  be 
one  of  the  smallest. 

The  tumor  having  been  determined  to  be  aneurismal,  the 
question  to  be  decided  is  what  treatment  will  most  safely  and 
speedily  relieve  the  patient.  The  curative  procedures  are  numer- 
ous, the  most  trustworthy  may  be  comprised  under  the  following 
heads:  compression,  induction  of  coagulation  by  means  of  con- 
stitutional remedies  which  slacken  the  circulation,  means  which 
act  directly  on  the  content  of  the  sack,  and  cause  coagulation, 
and  finally,  ligation.  These  methods  for  the  cure  of  aneurism 
have  already  l)cen  generally  considered  ;  a  more  detailed  account 
of  them  will  here  a|>pear. 

The  manner  in  which  the  cure  is  accomplished  is  through 
coagulation  of  the  blood  in  the  aneurismal  sack;  and  this  occurs 
when  the  blood  is  caused  to  move  slowly ;  it  may  take  place  when 


LTGATIOX    OF    THE    TRIMITIYE    CAROTID.  1105 

the  movement  is  wholly  suspended;  yet  under  the  latter  condi- 
tions, the  clot  that  is  formed  is  soft  and  ill  constituted  for 
permanence,  and  may  disintegrate,  and  induce  gangrene  in  the 
Avails  of  the  sack.  And  even  when  the  occluding  coagulum  has 
formed  slowly,  yet  if  the  mass  of  it  is  so  great  that  it  receives 
less  blood  than  is  needed  to  maintain  it  alive,  then  the  clot  may 
die,  and  the  superjacent  wall  sloughing  and  opening,  violent 
hsemorrhage  ensues,  which  usually  ends  the  patient's  life.  The 
conditions,  then,  under  which  the  treatment  may  successfully 
accomplish  its  purpose,  are  to  retard  the  movement  of  the  blood  in 
the  aneurismal  cavity;  and,  in  this  manner,  the  coagulating  blood 
will  deposit  itself  in  laj^ers  wdiich  will  assume  the  properties  of 
living  tissue  of  a  low  grade  of  organization.  And  whichever  of 
the  curative  procedures  here  mentioned  is  selected,  the  surgeon 
should  bear  in  mind  that  the  problem  of  cure  must  be  solved  in 
accordance  with  the  principles  just  mentioned,  w^hich  have  been 
established  by  the  painstaking  study  and  researches  of  Broca. 

Compression  may  be  done  digitally  or  mechanically :  that  is, 
W'ith  the  fingers,  or  with  some  appliance  by  which  pressure  is 
made  upon  the  vessel.  A  strong  and  trustworthy  nurse  can  do 
the  work  by  placing  two  fingers  of  one  hand  longitudinally  over 
the  vessel,  and  reenforcing  these  by  two  or  more  fingers  of  the 
other  hand,  placed  transversely  across  the  first.  As  fingers  tire, 
two  men  should  be  selected  for  the  work,  who  will  alternately 
relieve  each  other  in  the  task.  Too  much  pressure  which  will 
wholly  arrest  the  current  of  blood  is  faulty;  and  so  is  slight 
compression  which  will  permit  free  movement  of  blood  within 
the  aneurism.  Hence  those  doing  the  work  must  be  instructed, 
supervised  and  controlled;  the  rule  should  be  not  to  wholl}^ 
interrupt  the  blood-current,  some  jDulsatile  movement  should  be 
perceptible  in  the  vessel  beyond.  The  time  requisite  to  continue 
the  compression  varies  much  in  different  cases,  and  is  dependent 
on  certain  anatomical  conditions  of  the  walls  of  the  sack.  The 
form  and  size  of  the  opening  in  the  wall,  have  an  influence  in 
this  matter;  also,  whether  the  sack  so  lies  that  it  facilitates  or 
retards  the  return  of  the  blood.  If  the  inner  wall  of  the  sack 
presents  an  irregular  surface,  this  favors  the  coagulation  of  the 
blood.  For  such  reasons  an  aneurism  may  be  cured  by  compres- 
sion at  periods  varying  from  a  few  hours  to  several  days.  As 
criterion  that  the  compression  has  accomplished  its  purpose  is 
the  cessation  of  the  blowing  sound  and  the  pulsating  movement 
in  the  tumor :  it  must  be  added,  that  sometimes  when  occlusion 


JlUG  VESSELS   OK    TIIK    NECK. 

appears  lo  have  been  accoinplislie(],  the  })ulsatile  uiovement  of 
the  tumor  may  rt'appear  for  a  time,  and  then  vanish  perma- 
nently. 

Compression  lias  been  done  at  different  points,  viz.,  on  the 
proximal  side  of  the  tumor,  on  the  distal  side,  and  also,  directly 
on  the  tumor:  it  is  usually  made  on  tlie  cardiac  or  proximal  side; 
and  the  work  then  can  be  done  near  to,  or  reifiote  from,  the 
tumor;  compression  on  the  distal  side  is  only  done  in  cases  in 
which  it  is  not  practicable  to  make  it  on  the  cardiao  side.  And 
still  more  exceptionally,  the  compression  has  been  made  on  the 
tumor  itself.  As  is  known,  nearly  every  aneurismal  tumor  has 
a  tendency  to  spontaneous  occlusion  through  the  gradual  precipi- 
tation of  coagulated  blood  on  its  walls;  and  should  this  work 
have  advanced  near  to  the  stage  of  completion,  then  direct 
digital  pressure  might  soon  occlude  the  remaining  cavity.  An 
indication  that  the  tumor  is  one  suited  for  direct  compression 
Avould  be,  that  it  is  but  slightly  compressible  on  account  of 
thickness  of  its  Malls.  In  such  a  case  in  the  po})liteal  region, 
tlie  author  witnessed  the  curative  action  of  direct  compression 
accomplished  by  means  of  a  compressor  constructed  by  the 
patient  himself 

As  trustworthy  hands  cannot  always  be  obtained,  and  even  if 
they  could  be,  yet  fingers  tire,  and  cannot  act  with  the  steadiness 
and  unwavering  continuity  of  a  mechanical  appliance,  hence 
digital  compression,  once  so  much  resorted  to,  has  nearly  been 
superseded  by  the  mechanical,  in  which  a  device  is  used,  known 
as  the  arterial  compressor.  The  compressor  is  analogous  to  the 
tourniquet,  and  like  that  instrument  it  may  be  circular  or  semi- 
circular; and  in  each  form  it  is  so  constructed  that  the  action 
can  be  made  on  the  artery  while  the  adjacent  structures  are  free 
from  pressure,  and  the  circulation  in  them  is  not  arrested.  The 
horseshoe  or  semi-circular  compressor  accomjdishes  its  work  in 
this  manner;  outside  of  the  vessel  compressed,  the  circulation 
through  compensating  trunks  is  unimpeded. 

The  rules  given  in  regard  to  digital  compression,  apply  to 
mechanical:  the  work  must  not  be  overdone,  nor  defectively 
done:  the  passage  of  blood  through  the  vessel  must  not  be 
entirely  interrupted.  To  do  the  work  so  that  there  will  be  no 
danger  of  sloughing  from  excessive  compression  of  the  surface 
acted  on,  there  should  be  two  compressors,  which  will  act  alter- 
nately on  different  points.  For  the  treatment  of  aneurism  of  the 
carotid  artery  a  compressing  appliance  has  been  devised,  which 


LIGATION    OF    THE    PRIMITIVE    CAROTID,  1107 

is  similar  to  a  cravat  which  can  be  strapped  around  the  neck, 
and  pressure  made  on  the  artery,  where  desired.  In  the  use  of 
such  a  compressor,  some  trouble  has  been  found  in  so  fixing  the 
compressing  pad  that  it  will  not  shift  its  site.  Besides,  patients 
are  sometimes  intolerant  of  such  pressure;  in  one  case,  tlie 
patient,  after  having  made  trial  of  this  means,  declared  that 
nothing  could  induce  him  to  submit  further  to  the  compression. 

A  plan  of  treatment  occasionally  resorted  to  for  the  cure  of 
aneurism  is  the  administration  of  remedies  which  will  promote 
the  coagulation  of  blood  in  the  sack.  A  few  medicines  have  the 
repute  of  acting  tlius:  their  mode  of  action  is  difficult  to  explain. 
Agents  thus  administered  by  the  mouth  are  ergot  and  iodide  of 
potassium;  the  two  may  be  given  in  combination,  viz.,  a  drachm 
of  the  fluid  extract  of  ergot,  with  ten  grains  of  the  iodide  of 
potassium,  three  times  daily.  This  constitutional  medication  is 
resorted  to  chiefly  in  cases  in  wdiich  the  aneurism  is  inaccessible 
to  other  methods  of  treatment.  Such  curative  means  rarely  find 
use  in  the  treatment  of  aneurism  of  the  carotid  artery. 

A  third  method  of  treatment  is  the  employment  of  means 
which  act  directly  on  the  blood  in  the  sack  and  cause  its  coagu- 
lation ;  such  means  are  electricity  and  styptic  agents,  which,  being- 
introduced,  cause  coagulation. 

Ciniselli  has  made  extensive  trial  of  electricity  for  this  pur- 
pose;  he  used  the  static  current,  which  may  be  generated  by  a 
series  of  small  zinc  and  copper  plates,  connected  by  a  saline 
medium,  and  having  poles  terminating  in  needles,  which  can  be 
inserted  into  the  aneurism.  In  the  electrol3^tic  action  thus 
induced,  different  materials  are  drawn  towards  the  positive  and 
negative  poles,  viz.,  to  the  positive  one  acid  elements  are  attracted, 
while  alkaline  elements  are  drawn  towards  the  negative  pole:  as 
mnemonic  aid  to  retain  these  facts  in  memory  is  the  dissyllable 
panalk:  positive,  acid,  negative,  alkaline.  The  acid  materials 
which  collect  as  a  coagulum  about  the  positive  pole  are  firmer  in 
consistence  than  the  alkaline  matter  at  the  other  pole;  hence  it 
is  desirable  to  make  the  positive  pole  do  the  work  of  coagulation: 
and  to  accomplish  this,  the  positive  point  alone  should  enter  the 
tumor,  while  the  negative  one  may  be  placed  on  tlie  cutaneous 
surface  outside  of  the  aneurism.  The  skin  around  the  penetrat- 
ing needle  is  cauterized  by  the  electricity;  and  hence  the  action 
must  not  be  prolonged  too  far,  lest  a  large  section  of  the  skin  be 
caused  to  slough,  and  the  purpose  of  the  work  be  defeated  :  and 
also  the  needle  at  each  application  must  be  introduced  at  a 
■different  point. 


lies  VESSELS    OF    THE    NECK. 

Tiie  aneurisniul  .sack  luis  been  oeciiuled  \>y  iudueing  coagula- 
tion by  means  of  a  styptic  fluid,  which  is  injected  into  the  cavity. 
The  agents  most  employed  for  this  purpose  are  the  salts  of  iron; 
for  example,  a  solution  of  the  chloride  or  the  persulphate  of 
iron.  Such  a  solution  may  be  injected  by  means  of  a  hypodermic 
syringe;  and  this  must  be  done  carefully,  drop  by  drop.  As 
there  is  a  risk  that  the  coagulated  blood  may  not  remain  in  site, 
but  may  float  out  of  the  sack  into  the  general  current  of  blood, 
and  work  embolic  mischief  elsewhere,  tliis  ])l!in  of  treatment  lias, 
at  present,  few  or  no  advocates.  And  coagulating  injection,  if 
resorted  to  at  all,  is  reserved  for  the  cure  of  the  aneurismal 
varix,  in  which,  with  the  exercise  of  some  care,  there  is  but  slight 
risk  of  dislodging  the  coagulated  blood. 

The  most  usual  method  resorted  to  for  the  cure  of  aneurism 
is  the  ligation  of  the  vessel.  Where  the  vessel  is  easy  of  ap- 
proach, however,  an  endeavor  should  be  made  to  cure  by  com- 
pression: since  this  method  in  no  way  imperils  the  patient,  and 
does  not  preclude  a  resort  to  the  ligature,  should  compression  be 
unsuccessful. 

The  ligation  of  the  artery  for  the  cure  of  aneurism,  is  one  of 
the  signal  triumphs  of  surgery,  dating  from  the  early  part  of  the 
nineteenth  century.  The  first  successful  operation  was  that  of 
Sir  Astley  Cooper,  done  in  1805.  That  the  carotid  could  be  safely 
tied  had  been  proven  by  other  surgeons.  Fleming,  in  a  case  of 
attempted  suicide,  tied  the  carotid,  in  1803,  with  recovery.  And, 
prior  to  this,  the  ligation  had  been  successfully  done  by 
Hebenstreit.  The  first  ligation  of  Abernethy,  as  well  as  that  of 
Cooper,  resulted  in  failure;  later  Cooper  tied  the  primitive 
carotid  for  aneurism,  and  the  man  soon  recovered,  and  resumed 
his  occupation  as  a  laborer.  At  this  early  period,  it  recjuired  a 
bold  hand  to  essay  such  a  task,  when,  as  Allan  Burns  says, 
surgeons  were  "balanced  between  hope  and  fear"  as  to  the  results 
which  might  occur.  Secondary  haemorrhage  was  feared  as  the 
inevitable  sequent  of  such  a  venture.  Daring  hands  soon  put 
the  matter  to  the  crucial  question  of  trial,  and  the  answer  was 
satisfactory. 

As  remarks  Burns,  "In  no  operation  is  a  current  knowledge 
of  the  locality  of  the  parts  concerned  more  indispensable  than 
in  the  case  under  consideration."  And  these  difficulties  increase 
as  one  proceeds  from  the  distal  to  the  proximal  portion  of  the 
vessel.  Frequently  the  location  of  the  aneurism  is  such  that 
one  is  compelled  to  operate  low  in  the  neck.     When  done  low 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1109 

down,  besides  dividing  the  skin,  platysma  myoides  and  the 
cervical  fasciee,  the  sternal  bead  of  tbe  sterno-cleido-mastoid  must 
be  drawn  aside.  The  sheath  containing  the  artery,  vein  and 
vagus  nerve,  is  next  found,  and  when  opened,  the  next  difficult 
step  is  to  separate  the  interiial  jugular  vein  from  the  artery.  He 
who  is  only  familiar  with  the  parts  in  the  anatomical  room,  will 
be  surjDrised  at  the  ever-changing  volume  of  this  vein:  in 
inspiration  sinking  to  a  small  cord,  but  in  expiration  greatly 
swelling,  so  as  to  overlap  the  artery:  "and  the  transitions  from 
emptiness  to  fullness  are  so  rapid  that  sufficient  time  is  not  given 
to  detach  it  from  the  carotid."  In  the  w^ork  of  separating  the 
vein  from  the  artery,  the  former  has  sometimes  been  injured, 
and  no  ill  resulted;  and  the  writer  would  remark  that  in  his 
experience  in  detaching  the  femoral  vein  from  the  adjacent 
artery,  a  prick  of  the  former  has  caused  no  serious  trouble. 

In  the  low  ligation  on  the  left  side,  Burns  thinks  there  is  a 
risk  of  wounding  the  thoracic  duct,  which  he  finds  behind  the 
carotid,  in  some  subjects,  mounting  pretty  high  up  in  the  neck, 
before  it  curves  downwards  and  outwards  to  join  the  subclavian 
vein.  A  nerve  severed  may  reunite,  but  the  duct  w^ounded. 
Burns  thinks,  would  not  heal,  and  there  is  no  substitute  for  it. 
The  duct  here  is  diminutive,  and  especially  so  when  unfilled  by 
chyle;  yet  after  a  fall  meal,  it  is  so  swollen  that  the  containing 
chyle  is  visible  through  the  thin  walls  of  the  duct. 

The  possibility  of  arterial  anomaly  must  be  borne  in  mind, 
in  the  inferior  ligation  of  the  carotid;  instead  of  one  trunk,  there 
may  be  two  arteries  side  by  side,  viz.,  the  carotid  and  the  verte- 
bral arteries,  which  on  the  left  side  may  spring  from  tlie  arch  of 
the  aorta,  and  ascend  close  to  each  other;  and  also  on  the  right 
side,  the  two  have  been  found  close  together,  though  the  vertebral 
arose  from  its  normal  point.  In  such  a  dilemma,  pressure  made 
on  each  vessel  would  clear  up  all  uncertainty,  and  indicate  the 
one  to  be  chosen  for  ligation. 

The  bifurcation  of  the  carotid  sometimes  occurs  low  on  the 
neck,  and  in  that  case  the  surgeon  might  be  embarrassed  to 
know  what  the  conditions  were,  and  what  vessels  he  had  before 
him;  as  aid  in  such  a  case  would  be  branches  arising  from  one 
trunk,  w^hich  would  denote  the  external  carotid. 

If  ligation  be  done  for  the  cure  of  aneurism,  it  may  be  done 
on  the  proximal  side,  close  to,  or  remote  from,  the  tumor.  The 
operation  done  near  the  aneurism  on  the  cardiac  side  is  known 
as  that  of  Anel,  an  Italian  surgeon  who  had  the  good  fortune  to 


1110  VKSSELS   OF    THK    XKCK. 

be  the  pioneer  in  this  oj)eration,  and  thus  to  secure  a  })ennanent 
place  in  surgical  literature,  especially  among  French  writers.  If 
the  ligature  approach  more  toward  the  heart,  the  name  of  Hunter 
is  affixed  to  the  operation  by  English  authors.  The  o|)eration  of 
Hunter  is  the  preferable  one  where  this  is  practicable;  but  should 
space  not  permit  this,  then  the  less  desirable  site  of  Anel  must, 
perforce,  be  adopted.  And,  again,  if  the  aneurism  occupy  the 
first  portion  of  the  artery,  where  proximal  ligation  would  not  be 
possible,  then  distal  ligation  must  be  done;  and  this  procedure 
having  been  first  proi)Osed  or  done  by  a  French  surgeon,  Brasdor, 
his  name  has  been  given  to  the  operation. 

Of  the  three  sites  mentioned, the  Hunterian  offers  more  chances 
for  a  successful  issue  to  the  jtatient  than  can  be  obtained  by  tliat 
of  Anel  or  Brasdor:  the  closeness  of  the  ligation  to  the  aneurism 
in  the  operation  of  Anel  disposes  to  secondary  hsemorrhnge;  and 
to  the  operation  of  Brasdor  there  are  serious  anatomical  and 
physical  objections. 

The  method  of  performing  ligation  has  been  the  subject  of 
much  modification:  as  done  by  8ir  Astley  Cooper,  the  work  first 
consisted  in  finding  the  artery,  and  tying  it  at  two  points  near 
each  other,  and  then  severing  the  vessel  between  the  ligatures. 
One  end  of  each  cord  was  allowel  to  remain  long,  while  the 
other  was  cut  short;  and  the  wound  was  then  closed  by  sutures, 
with  the  two  threads  projecting  from  it.  Thus  the  operation  for 
the  cure  of  an  aneurism  was  first  done  by  Sir  Astley  Cooper;  and, 
as  he  records,  "the  first  ligature  came  away  on  the  twenty-second 
day,  and  the  second  one,  on  the  twenty-third  day  after  the 
ligation.  The  wound  was  along  time  in  healing:  first  from  a 
sinus  in  the  course  of  the  ligatures,  and  afterward,  from  a  fungus 
where  the  sinus  had  formed.  The  man  was  discharged  well  in 
about  twelve  weeks  after  the  ligation  was  done." 

The  purpose  intended  by  doubly  tying  and  dividing  the 
vessel  was  to  put  at  rest  the  distal  portion,  and  thus  favor  the 
coagulation  in  the  tumor. 

The  way  so  beset  with  apprehended  perils  having  been  safely 
traversed,  the  surgical  world  elsewhere  was  not  tardy  in  following 
in  the  footsteps  of  the  great  English  surgeon.  The  plan  of 
doubly  ligating  was  soon  superseded  by  that  of  the  single  ligature; 
and  then  the  continuity  of  the  vessel  was  interrupted  and  severed 
by  the  including  ligature  sloughing  out,  after  a  few  week.s. 
These  early  methods,  reflecting  honor  on  those  who  introduced 
them,   have  been  succeeded  by   those  which   are  simpler  and 


LIGATION    OF    THE    PEIMITIVE    CAROTID.  1111 

safer  in  their  action.  The  small  silken  cord  which  has  been 
rendered  aseptic  is  used  for  the  ligature;  and  the  artery  being 
tied,  both  ends  of  the  thread  are  cut  short,  and  the  wound  is 
closed,  and  the  work  so  done  that  healing  is  obtained  by  primary 
union.  Instead  of  silk,  catgut  cord  is  often  used  for  arterial  liga- 
tion. Strangely  enough  catgut  cord  was  tried  and  rejected  by 
Sir  Astley  Coojjer. 

The  anterior  or  inner  margin  of  the  sterno-cleido-mastoid 
muscle  serves  as  a  guide  to  find  the  jDrimitive  carotid  in  a  great 
portion  of  its  course:  but  as  the  artery  ascends,  it  inclines  inwards 
from  the  muscle;  and  the  result  is  that  in  its  upper  portion,  the 
artery  has  but  a  slight  covering  of  soft  parts,  while  near  the 
sternum,  the  vessel  lies  behind  the  sternal  portion  of  the  muscle; 
and  this  has  led  one  surgical  authority  to  give  the  rule  to  seek 
for  the  vessel  in  tlie  interspace  between  the  sternal  and  clavicular 
portions  of  the  muscle.  Though  the  inner  edge  of  the  muscle 
serves  as  a  guide  to  the  artery,  yet  a  more  satisfactory  guide  is  a 
line  drawn  from  the  slight  fossa  behind  the  lobule  of  the  ear  to 
the  sterno-clavicular  articulation;  and  such  a  line  below  will  lie 
over  the  inter-muscular  interstice  just  named.  Tliis  cutaneous 
line  above,  lies  over  the  external  carotid  artery,  and,  hence,  it 
enables  one  to  find  this  vessel  also. 

By  the  aid  of  the  guide  given,  it  is  easy  to  find  the  common 
carotid  artery,  in  the  lean  subject;  but  in  one  of  short,  thick, 
rotund  neck,  in  which  there  is  a  deep  layer  of  fatty  tissue,  the 
ligation  becomes  a  more  difficult  undertaking:  the  primary  cut 
must  be  longer  than  usual  to  permit  of  penetration  to  the  vessel. 

The  patient  must  lie  on  the  back  with  the  shoulders  uplifted 
upon  a  pillow,  or  cushion,  so  situated  that  the  head  will  fall 
backwards,  and  the  neck  will  be  accessible.  This  position  shifts 
•the  artery,  somewhat  in  reference  to  the  adjacent  muscle:  espe- 
cially in  its  upper  portion.  The  pulsating  movement  of  the 
artery  indicates  its  position ;  yet,  sometimes  this  movement  is  so 
feeble  that  it  is  scarcely  sensible  to  the  touch ;  and  this  feeble- 
ness is  especially  present  in  cases  in  which  the  heart  has  been 
weakened  by  the  loss  of  much  blood:  also  in  the  patient  who  has 
been  profoundly  anaesthetized. 

In  the  emaciated  subject,  a  short  cutaneous  cut  made  in  the 
carotidean  landmark  will  suffice;  but  if  the  subject  be  one  of 
short,  thick  neck,  then  the  outer  cut  must  be  a  long  one;  and 
the  incision  should  be  made  by  first  penetrating  quite  through 
the  skin:  an  act  in  which  the  scalpel  stands  upright;  then  tlie 


1112  VKSSELS    OF    THE    NECK. 

handle  of  the  instrument  .'^liouhl  bo  lowered,  but  raised  to  a 
per])eiidicular  again  when  it  reaches  the  end  of  the  incision.  By 
thus  incising,  no  space  will  be  lost  at  tiie  ends  through  the  skin 
liaving  been  incompletely  divided.  The  ])lunt-pointed  retractors 
are  to  be  inserted,  and  committed  to  an  aid,  who  has  been 
instructed  not  to  displace  the  wound  by  pulling  the  lips  too 
much  towards  one  side,  or  the  other.  As  the  work  proceeds,  the 
sterno-cleido-mastoid  muscle  will  be  encountered,  and,  unless 
the  ligation  be  in  the  lower  fourth  of  the  carotid,  the  muscle 
must  be  pulled  externally,  by  inserting  the  retractor  under  its 
margin.  But  if  tiie  tying  be  done  near  the  sternum,  then  it  is 
recommended  by  Zang  that  the  incision  be  made  between  the 
sternal  and  clavicular  portions  of  the  muscle;  and  to  obtain  room 
the  sternal  portion  must  be  drawn  inwards.  Or,  in  this  inferior 
ligation,  the  plan  of  Coates  may  be  followed,  wdiich  was  to  make 
an  incision  on  the  inside  of  the  sternal  limb  of  the  muscle,  and 
then  having  passed  a  grooved  guide  under  this  portion,  the  latter 
is  to  be  severed  from  the  sternum.  The  writer  may  state  that  in 
a  few  ligations  below  the  omo-hyoid  muscle,  he  has  found  it 
possible  to  reach  the  vessel  by  a  cut  made  between  the  trachea 
and  the  muscle:  and  when  the  inner  edge  of  the  latter  is  exposed, 
if  the  head  be  pulled  to  one  side,  the  muscle  may  be  drawn 
outwards  and  the  vessel  reached. 

In  making  this  cut  to  reach  the  vessel,  small  vessels,  chief! 3' 
veins,  are  often  met;  and  as  a  bloodless  field  is  necessary  to 
enable  the  surgeon  to  carry  his  work  to  completion,  these  vessels 
should  be  caught  and  subjected  to  torsion,  so  as  to  close  them: 
torsion  is  better  than  tying,  since  the  latter  would  leave  material 
in  the  wound  that  would  retard  immediate  closure. 

There  is  no  point  where  the  artery  cannot  be  reached,  if  the 
operator  has  freshened  his  anatomical  knowledge  by  a  recent 
rehearsal  on  the  cadaver;  and  disciplined  by  such  rehearsal,  the 
operator  will  encounter  no  difficulties  which  he  cannot  vanquish, 
tuto  etjucimde.  Tlie  artery  lies  in  a  sheath-like  envelope  along 
with  the  internal  jugular  vein  and  the  pneumogastric  nerve: 
and  the  latter  two  must  not  be  included  in  the  ligature.  The 
sheath  should  be  caught  up  with  the  forceps,  and  uplifted  so  as 
to  form  a  conoidal  figure,  of  which  the  apex  is  held  by  the 
forceps.  This  act,  though  simply  told,  is  less  simple  in  accom- 
plishment: for  in  catching  the  sheath,  it  is  easy  to  include  the 
tunica  adventitia  of  the  artery:  and  to  be  sure  that  the  latter  is 
not  seized,  the  uplifted  cone  should  be  moved  in  different  direc- 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1113 

tioiis,  when  the  seizure  or  exclusion  of  the  artery  will  be 
determined.  Should  the  error  be  committed  of  including  the 
arterial  wall,  then  in  the  section  of  the  uplifted  cone,  the  artery- 
might  be  opened,  or  wounded.  The  inexperienced  may  have 
trouble  in  distinguishing  the  sheatli  from  the  outer  arterial  tunic 
especially  if  there  be  adhesion  between  tlie  parts  due  to  some 
morbid  action:  yet  in  normal  state,  the  sheath  is  easily  moved 
on  the  arter}'. 

Should  the  operating  hand  be  inexperienced,  and  the  index 
not  versed  to  the  nail  in  finding  the  right  way  through  the 
tissues,  then  instead  of  thus  uplifting  the  vaginal  cone,  the 
operator  had  better  substitute  the  simpler  plan  of  scratching 
through  the  sheatli  with  a  grooved  director:  and  as  evidence  that 
he  is  wounding  the  sheath  and  not  the  artery,  will  be  the  slight 
bleeding  from  opening  the  vasa  vasorum  which  abound  in  the 
sheath;  and  also  that  as  soon  as  this  latter  has  been  perforated, 
the  grooved  director  can  be  inserted  between  the  vessel  and  the 
sheath.  That  these  minute  directions  are  not  pedantic  refine- 
ments more  calculated  to  mislead  than  to  guide,  the  writer  is 
certain;  experience  ma}'  not  need  them,  yet  inexperience  will 
have  use  for  them. 

The  next  step,  when  the  sheath  has  been  opened,  is  to  extend 
this  opening  a  quarter  of  an  inch  upwards  and  downwards,  in  a 
longitudinal  direction:  and  tliis  can  be  done  with  a  blunt 
bistoury  on  the  grooved  director;  or  with  small  blunt  scissors. 
Through  the  opening  thus  made,  the  aneurismal  needle  can  be 
passed  and  carried  underneath  the  vessel,  so  that  its  point  will 
emerge  on  the  opposite  side  near  where  it  entered:  and  if  this 
be  carefully  done,  the  vessel  will  be  included  in  the  hollow  of  the 
needle,  with  but  slight  disturbance  of  the  sheath.  In  this  act, 
the  sheath  should  be  detached  as  little  as  possible  from  the  artery. 
When  the  aneurismal  needle  has  thus  been  carried  underneath 
the  artery,  the  thread  must  be  passed  into  the  needle's  point,  and 
the  instrument  removed  so  as  to  draw  the  thread  beneath  the 
vessel.  The  aneurismal  needle  may  have  a  movable  point,  which 
can  be  detached;  and  this  form,  which  is  known  as  Mott's  needle, 
is  easily  used,  since  when  it  has  been  passed  beneath  the  artery, 
the  point  can  be  unscrewed  and  removed;  thus  the  attached 
thread  w^ill  be  carried  under  the  artery.  This  needle  is  accom- 
panied by  a  key  which  is  used  to  detach  the  movable  point. 

In  the  absence  of  the  Mott  needle,  or  that  with  immovable 
point,  the  surgeon  can  easily  construct  a  substitute :  a  piece  of 
71 


1114  VESSELS    OF    THE    NECK. 

iron  wire  bent  on  itself  so  as  to  be  in  loop-form,  can  be  inserted 
in  the  fenestra  in  the  sheath,  and  carried  beneath  and  around  the 
vessel:  and  when  the  loop  api)ears,  the  thread  can  be  passed 
through  it,  and  drawn  beneath  the  vessel.  From  experience,  the 
writer  can  bear  witness  to  the  facilit}'  with  which  the  ligature 
can  thus  bo  carried  around  the  artery. 

Of  the  materials  used  for  ligature,  viz.,  thread  of  cotton,  linen, 
catgut,  silk,  or  wire,  the  autlior  prefers  the  simple  silken  thread  : 
and  before  using  this,  it  should  be  immersed  in  alcohol  for  an 
hour,  by  which  it  is  rendered  aseptic.  The  tying  is  next  to  be 
done,  and  this  must  be  effected  by  a  simple  square  knot.  The 
old  method  of  drawing  the  thread  so  tightly  as  to  divide  the 
inner  and  middle  coats  of  the  vessel  is  unnecessary;  the  purpose 
will  be  accomplished  if  the  constriction  be  carried  to  the  extent 
of  bringing  the  inner  walls  together,  so  as  to  entirely  close  the 
artery  and  prevent  the  passage  of  the  blood.  It  is  not  necessar}' 
to  divide  the  artery  as  was  ultimately  accomplished  by  the  former 
method  of  very  tight  tying.  When  done  with  aseptic  silken 
thread,  the  latter  is  cut  short,  and  finally  becomes  encapsulated 
in  the  tissues. 

The  tying  being  completed,  there  should  next  be  laid  a  thread 
or  two  of  aseptic  silk,  or  catgut,  in  the  wound,  so  placed  that  one 
end  will  hang  outside.  This  thread  replaces  the  drainage  tube, 
formerly  used;  and  it  serves  as  a  vehicle  for  conducting  outwards 
the  excreta  which  may  form  in  the  cavity  of  the  wound.  Next  a 
.sufficient  number  of  sutures  must  be  inserted  to  close  the  wound. 
Over  the  wound,  lint  saturated  with  alcoholic  lotion  (twenty-five 
one-hundredths)  is  to  be  placed,  and  retained  in  site  by  a  circular 
bandage.  The  lint  must  be  retained  moist  by  occasionally 
remoistening  it  with  the  lotion.  The  threads  for  drainage  are 
to  be  daily  observed,  and  on  the  second  or  third  day,  one  may 
be  removed;  and  as  soon  as  all  excreta  cease  to  appear,  the  last 
thread  may  be  removed.  The  excreted  material  is  usually 
small  in  quantity;  and  the  wound  will  heal  in  a  few  days; 
complete  closure  with  firm  union  of  the  walls  of  the  wound  can 
be  obtained  in  from  ten  to  fourteen  days.  To  favor  rapid  heal- 
ing, the  patient  should  lie  in  bed,  and  the  head  should  be 
retained  as  nearly  motionless  as  possible,  during  the  treatment; 
and  care  should  be  used  to  avoid  much  movement  of  the 
neck,  for  at  least  twenty-five  days:  for  this  precaution  being 
neglected,  the  site  of  the  wound  may  be  inflamed  and  suppura- 
tion take  place;  and  such  accident  occurring,  not  only  is   the 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1115 

treatment  prolonged,  but  there  is  the  risk  of  secondarj^  bleeding. 
The  author  had  a  case  which  took  this  unfortunate  course,  and, 
despite  the  various  means  that  were  tried  to  control  the  haemor- 
rhage, the  bleeding  recurred  from  time  to  time,  until  life  was 
terminated  by  exhaustion.  To  avoid  such  catastrophe,  the 
patient  should  be  enjoined  to  keep  the  part  at  rest,  for  at  least  a 
couple  of  weeks  after  the  wound  has  healed. 

The  carotid  has  also  been  tied  for  the  relief  of  epilepsy  or 
neuralgia  seated  in  the  head.  When  the  brain  of  the  epileptic 
subject  is  seen  during  his  convulsive  paroxysm,  the  anaemic 
condition  in  which  it  has  been  observed  by  Brown-Se'quard  and 
others,  would  contraindicate  ligation  as  a  means  of  relief:  indeed, 
the  consequent  detraction  from  the  normal  supply  of  blood, 
should  assist,  and  not  resist,  this  reported  causal  agency  of 
epilepsy.  In  the  light  of  present  knowledge,  the  author  neither 
counsels  nor  rejects  this  procedure,  since  it  may  be  said  to  be  on 
trial  as  one  of  the  heroic  measures  for  the  cure  of  epilepsy.  Epi- 
lepsy finds  its  causation  in  so  many  agencies  located  centrally  or 
peripherally,  that  he  who  treats  the  disease  is  warranted  in 
freighting  his  therapeutic  sling  with  many  pebbles;  and  if  he 
includes  this  one  from  the  stream  of  surgery,  it  caniiot  prove 
more  vakieless  than  many  others  which  he  may  essay;  and 
should  it  cure  the  patient,  the  latter  will  be  content,  and  the 
physiological  therapeutist  will  have  had  an  experience  which  he 
may  share  with  the  empirical  practitioner  who  is  satisfied  with 
effect,  but  leaves  to  the  scientist  the  search  for  a  cause. 

The  ligation  of  the  carotid  for  the  relief  of  cranial  or  cephalic 
neuralgia  has  proved  successful  in  some  cases;  and  its  mode  of 
action  consists  in  diminishing  the  amount,  and,  consequently,  the 
pressure  of  tlie  blood,  in  the  affected  part.  After  ligation,  the 
pulse-wave  vanishes,  for  a  time,  in  the  branches  of  the  tied  carotid, 
and  though  blood  reaches  them  through  compensating  channels, 
yet  it  is  a  long  time  before  normal  pressure  and  pulsation  are 
restored:  meantime,  pain  may  disappear  through  the  affected 
part  being  restored  to  integrity.  There  is  a  risk  that  the  cure 
will  not  be  permanent,  and  that,  when  the  circulation  becomes 
normal,  the  neuralgia  may  return.  An  example  of  this  fell  under 
the  writer's  observation.  In  1868,  in  a  man  who  was  the  victim 
of  atrocious  pain  on  the  side  of  the  head,  especially  in  the  tem- 
poral and  parietal  region,  other  means  having  failed  to  relieve, 
the  writer  tied  the  right  carotid  artery.  The  patient  was,  at 
once,  free  from  his  pain;  and  this  relief  continued  for  nearly  a 


1110  VESSELS   OF   THE   NECK. 

year,  when  the  trouble  reappeared,  and  continued  until  the  man's 
death,  some  two  years  afterwards. 

In  1867,  Carnochan  advised  and  practiced  ligation  of  vessels 
for  the  cure  of  elephantiasis;  thus  he  successfully  treated  a  case 
of  elephantiasis  of  the  face:  he  first  tied  the  corresponding  primi- 
tive carotid;  and  six  months  afterwards,he  tied  theotlier  carotid. 
The  result  was  a  gradual  shrinkage  of  the  hyperlrophied  struc- 
ture, which  continued  for  eight  years. 

Ligation  has  sometimes  been  done  as  a  preliminary  step  to 
the  removal  of  growths  in  the  region  supplied  by  the  vessel;  for 
this  object,  such  ligation  has  been  strongly  advocated  by  Verneuil 
for  the  subjoined  reasons:  it  guards  against  exhaustive  haemor- 
rhage, and  thus  the  surgeon  is  not  disturbed  by  bleeding  from 
vessels  which  he  may  wound  during  his  operative  work ;  and 
finall}',  through  the  lessened  attlux  to  the  parts  operated  upon, 
the  subsequent  inflammation  will  be  lessened  or  quite  prevented. 
Richet  opposes  the  procedure,  claiming  that  in  the  rapid  reap- 
pearance of  the  blood  in  the  vessel  beyond  the  ligated  i)oint,  the 
loss  of  blood  is  by  no  means  avoided;  and  a  still  graver  objection 
urged  by  Richet  is  in  the  encephalic  disturbance  which  the  liga- 
tion can  occasion. 

For  many  years  the  writer  has  practiced  preliminary  ligation 
of  the  carotid  in  cases  in  which  the  internal  carotid  or  the  exter- 
nal carotid  artery  might  be  opened  in  surgical  operations:  and  he 
has  not  encountered  severe  bleeding  from  the  reappearance  of 
blood  in  the  opened  vessels;  nor  in  tlie  cases  thus  treated  has 
cerebral  disturbance  arisen.  Hence  he  advocates  preliminary 
ligation  of  the  carotid  in  operations  wliich  otherwise  must  be 
attended  by  much  loss  of  blood;  an  exception  to  this  would  be 
where  the  preliminary  tying  of  the  external  carotid  would  serve 
a  similar  purpose.  In  the  amputation  of  limbs  the  author's  cus- 
tom has  been,  as  a  substitute  for  the  tourniquet,  to  preliminarily 
tie  the  main  artery  a  short  distance  above  the  site  of  amputation: 
thus  doing,  the  operator  greatly  lessens  the  loss  of  blood,  and 
husbands  the  vital  resources  for  the  demands  which  are  about  to 
be  made  on  them. 

Reference  has  been  made  to  the  disturbance  which  can  be 
caused  in  the  head  by  ligation  of  the  carotid  artery.  That  such 
complication  is  not  infrequent  appears  from  the  figures  of  Pilz 
of  Breslau,  who  finds  in  a  list  of  six  hundred  ligations  that  cere- 
bral symptoms  arose  in  about  one-third  of  the  operations;  and  or 
these,  fifty-six  per  cent  died.     These  figures  vary  somewhat  from 


LIGATION    OF    THE    PRIMITIVE    CAROTID.  1117 

those  reported  by  Reis  in  the  Archiv  flir  Klinische  Chirurgie:  he 
presents  a  collection  of  seventy-three  ligations,  in  which  cerebral 
disease  appeared  in  seventeen  cases,  viz.,  about  twenty-three  per 
cent.  From  the  writer's  personal  experience,  and  from  observa- 
tion of  the  operations  of  others,  he  is  convinced  that  these  figures 
are  too  high.  The  diminished  frequency  of  such  cerebral  com- 
plication maybe  attributed  to  the  superior  methods  which  obtain 
in  the  surgical  work  of  the  present  time.  The  quondam  out- 
hanging  thread  that  was  suspended  to  the  artery,  besides 
being  a  standing  menace  of  secondary  bleeding  until  its  detach- 
ment and  closure  of  the  sinus  in  which  it  lay,  also  maintained  a 
chronic  inflammation  of  the  site  of  ligation:  an  inflammation 
tliat  may  implicate  the  sympathetic  plexus  of  nerves  which 
embrace,  or  lie  near,  the  carotid  artery.  The  rapid  cure  now 
effected  by  the  buried  aseptic  ligature  lessens  or  prevents  such 
irritation:  so,  that  in  future,  it  is  probable  that  such  cerebral 
complication  will  be  a  matter  of  infrequent  occurrence. 

Cerebral  complication  following  carotid  ligature  has  appeared 
at  once,  after  the  operation,  or  it  has  supervened  at  a  later 
period. 

As  primary  or  immediate  consequences  are  dizziness,  tendency 
to  sleep,  palpitation  of  the  heart,  and  painful  or  abnormal  sensa- 
tions on  the  side  of  the  head  corresponding  to  the  ligature. 
There  may  be  cough,  and  muscular  spasms  general,  or  limited  to 
one  or  more  groups  of  muscles.  The  muscles  of  the  lar^aix  and 
of  the  pharynx  are  sometimes  implicated,  inducing  aphonia  and 
difiS.culty  of  swallowing.  The  muscular  disturbance  may  be 
confined  to  one  side  of  the  body,  or  both  sides  may  be  affected. 
These  disturbances  may  be  transient;  or  they  may  appearand 
disappear;  or  they  may  continue  for  a  considerable  period. 

Instead  of  appearing  immediately,  the  morbid  phfenomena 
caused  Ijy  ligation  may  occur  some  time  after  the  operation. 
These  disturbances  can  be  divided  into  three  classes:  mental, 
sensory  and  motor.  Mental  disturbance  commonly  presents 
itself  in  the  form  of  lessened  power  of  the  mind,  viz.,  loss  of 
memory,  and  inertia  of  the  thinking  power,  which  may  reach 
to  absolute  dementia;  the  patient  then  quite  loses  the  capacity 
of  caring  for  himself. 

Sensory  disturbance  may  exist  in  perverted  function  of  one  or 
more  of  the  special  senses,  especially  of  vision;  also  of  common 
sensation,  which  may  be  unilateral  or  universal  in  extent.  Deaf- 
ness has  also  been  observed. 


Ills  VESSELS    OF    THE    NECK. 

As  result  of  ligation  of  the  carotid,  motor  power  may  be  lost 
on  one  side  of  the  body;  and  tliis  is  on  the  side  opposite  to  that 
of  the  ligation  for  all  portions  of  the  body  except  the  face,  where 
the  palsy  corresponds  to  the  side  ligated.  Palpitation  of  the 
heart  and  difhculty  of  breathing  have  been  so  violent  in  some 
cases  as  to  speedily  terminate  life. 

Aphonia  arising  from  ligation  of  the  carotid  has  been  studied 
by  Ehrmann,  who  published  a  dissertation  on  the  subject  in 
18GG,  in  which  he  states  that  writers  have  disagreed  in  reference 
to  the  causation.  Horner  finds  the  cause  in  an  increased  afflux 
of  blood  to  the  thyroid  gland;  Bertherand  refers  it  to  the  lesion, 
or  inclusion  of  filaments  of  tlie  sym})athetic  nerve  in  the  ligature ; 
Giraldes  attributes  the  loss  of  voice  to  swelling  of  the  wound  that 
crowds  on  the  vagus  nerve;  Broca  thinks  it  ma}^  be  due  to  a 
neuritis  of  the  vagus  through  lesion  of  the  nerve.  In  a  case  of 
ligation  done  by  the  writer  in  which  the  cause  was  evidently 
referable  to  inclusion  of  the  sympathetic  nerve,  the  aphonia  was 
not  complete,  yet  it  remained  until  the  death  of  the  patient,  some 
weeks  afterwards. 

As  a  rule,  this  aphonia  is  not  })ermanent:  in  one  case  it  dis- 
appeared after  two  weeks;  and  in  others  it  vanished  after  some 
months.  It  is,  also,  of  infrequent  occurrence;  for  Ehrmann  found 
that  in  a  series  of  two  hundred  and  seventeen  ligations  it  was 
rarely  observed.  In  one  case  in  which  a  necropsy  was  made,  the 
vagus  was  found  divided  by  the  ligature.  And  in  another  case 
of  aphonia,  there  had  been  thrown  a  provisional  ligature  around 
the  external  carotid,  and  though  the  knot  was  not  tied,  yet  the 
voice  was  extinguished. 

The  writer  believes  that  such  aphonia  is  wholl}-  due  to  lesion 
of  nervous  filaments  in  the  work  of  tying:  such  lesion  arising 
from  mal-adroit  manipulation  in  exposing  the  vessel,  and  pass- 
ing the  thread  around  it.  In  the  case  seen  by  the  writer,  the 
patient  was  bleeding  from  a  wound  of  the  external  carotid;  and  so 
profuse  was  the  haemorrhage  that  precipitate  haste  was  necessary 
in  order  to  rescue  the  patient  from  fatal  Ijleeding.  Though  the 
conditions  were  not  verified  subsequently  by  a  necropsy,  yet  there 
is  no  doubt  that  in  tlie  hasty  manipulation,  the  vagus  was 
included. 

In  regard  to  most  of  the  accidents  enumerated  which  may 
follow  ligation  of  the  carotid,  whether  occurring  primarily  or 
ulteriorly,  they  may  be  referred  to  disturbed  encephalic  circulation, 
throueh  the  closure  of  a  channel  through  which  the  brain  receives 


LIGATION    OF    THE    PRIMITIVE    CAROTID,  1119 

more  than  one-fourth  of  its  supply  of  blood.  In  this  condition, 
the  nutrition  of  a  portion  of  the  brain  must  be  disturbed;  for  a 
time,  the  current,  in  which  the  blood  reaches  its  destination  by 
stagnant  reflux,  rather  than  by  normal  afflux,  fails  to  maintain 
those  fine  metaplastic  processes  of  elementary  interchange,  by 
which  the  normal  life  of  animal  tissue  is  maintained.  Another 
agency  which  may  have  a  disturbing  influence  moy  be  an  irreg- 
ularity in  the  formation  of  the  circle  of  Willis:  thus,  as  the  writer 
has  observed  in  dissection,  one  of  the  posterior  communicating 
branches  which  connect  the  internal  carotids  with  the  posterior 
cerebral  arteries  may  be  unusually  small;  and  also  tlie  anterior 
communicating  trunk  of  the  circle  may  be  small.  Such  an 
irregularity  must  have  an  important  bearing  after  ligation  of  the 
common  carotid,  or  vertebral  artery. 

That  the  work  of  molecular  interchange  may  be  disturbed  by 
ligation  of  the  carotid  was  illustrated  in  a  case  in  which  the 
writer  ligated  the  vessel  as  aid  in  an  extensive  operation  done 
for  the  removal  of  a  cancer  involving  the  side  of  the  tongue  and 
the  pharynx.  A  few  days  after  the  operation,  the  patient  became 
hemijDlegic  on  the  side  of  the  ligation.  As  the  palsy  appeared 
almost  instantaneously,  it  was  deemed  to  be  dependent  on  the 
sudden  rupture  of  a  vessel:  and  with  the  hope  of  finding  a 
thrombus  that  could  be  removed,  and  relief  thus  obtained,  the 
cranium  was  opened  and  the  brain  exjiosed  corresponding  to  the 
motor  tract.  No  clot  was  found,  and  the  uncovered  cortex 
instead  of  being  the  site  of  hypersemia,  was  pale,  and  the  vessels 
of  the  investing  pia  mater  were  nearly  empty  of  blood.  The 
cerebral  structure  was  abnormally  soft,  and  was  in  the  initial 
stage  of  softening.  And  along  with  the  motor  tract  the  con- 
tiguous surface  of  the  cerebrum  participated  in  the  structural 
degeneration. 

Besides  the  interruption  and  disturbance  of  the  blood  supply, 
just  assigned  as  causation  of  the  cerebral  trouble,  it  is  probable 
that  there  are  faulty  or  dyscrasic  conditions  of  the  body  which  are 
predisposing  contributory  agencies;  and  as  examples  of  such 
agency  may  be  cited  that  of  vitality  depressed  through  renal 
disease,  ill  assimilation  of  nutriment,  or  other  enfeeblino-  ailment. 
In  tlie  presence  of  such  constitutional  condition,  any  severe 
surgical  assault  is  ill  tolerated;  and  if  delay  be  permitted 
before  operating,  the  surgeon  should  subject  his  patient  to  treat- 
ment which  will  improve  his  condition,  and  add  to  his  power 
of  resistance;  in  some  cases,  unfortunatel3%  the  urgent  demand 


1120  VE^.SEJ.S   OF   THE    XECK. 

for  immediate  ligation  gives  no  truce  for  preparatory  fortification. 

LUjation  of  BotJt  Prhnitive  Carotids. — Tlie  essays  in  the  work  of 
simultaneously  tying  botli  carotid  arteries  have  almost  uniformly 
terminated  disastrously.  Valentine  Mott  reports  a  case  in  which 
lie  tied  at  once  the  two  vessels,  and  death  occurred  a  few  liours 
afterwards.  Key,  of  London,  tied  the  right  carotid,  and  death 
having  quickly  followed,  the  necropsy  showed  that  the  left 
carotid  was  nearly  obliterated,  and  that  the  fatal  result  occurred 
under  conditions  similar  to  simultaneous  ligation  of  both  vessels. 
The  result  has  been  different  where  an  interval  of  a  week  or 
more  of  time  has  intervened  between  the  ligations.  And  experi- 
ence in  this  operative  field  has  shown  that  ligation  of  both 
vessels  with  a  considerable  interval  of  time  between  the  two 
operations  is  not  only  tolerated,  but  that  the  cliance  of  cerebral 
disturbance,  occurring  after  such  double  ligation,  is  not  greater 
than  after  single  ligation. 

The  writer  has  demonstrated  that  simultaneous  ligation  of 
both  carotids  is  jDOssible  without  any  ill  result  to  the  patient. 
Six  years  prior  to  the  date  of  this  writing,  in  the  removal  of  an 
epithelial  cancer  which  occupied  the  right  side  of  the  base  of  the 
tongue,  and  the  right  pharyngeal  arch,  the  internal  carotid  was 
opened,  and  despite  ligations  of  the  right  carotid,  the  haemor- 
rhage recurred  so  profusely  that  the  patient's  death  was  immi- 
nent. Comj^ression  within  the  throat  did  not  check  the  bleeding; 
and  when  the  patient  was  moribund,  the  left  primitive  carotid 
was  reached  by  a  rapid  incision  through  the  skin,  and  quick 
digital  penetration  to  the  vessel,  when  the  latter  was  tied.  The 
left  carotid  artery  was  ligatod  in  less  than  one  hour  after  the 
right  one  hud  been  tied.  And  even  this  double  ligation  did  not 
prevent  some  oozing  of  blood  from  the  pharyngeal  wound:  a  fact 
demonstrating  how  rapidly  the  blood  of  the  vertebral  arteries 
traversed  the  circle  of  Willis  and  reappeared  in  the  carotids. 
This  patient  made  an  uninterrupted  recovery,  disturbed  by  no 
cerebral  or  other  complication ;  and  the  freedom  from  such  com- 
plication the  writer  refers  to  the  loss  of  blood  which  occurred: 
and  should  he  find  it  necessar}'-  to  perform  simultaneous  ligation 
where  such  loss  has  not  already  occurred,  the  author  would 
premise  the  work  by  a  vigorous  bleeding.  The  history  here 
referred  to  is  interesting,  as  this  is  the  first  case  of  simultaneous 
ligation  of  the  primitive  carotids  which  has  tei-minatod  success- 
fully. 

Ligation  oj  the  Ext (rnal  Carotid.  Artery. — In  recent  years  the 


LIGATION    OF   THE    EXTERNAL    CAROTID   ARTERY.  1121 

ligation  of  the  external  carotid  lias  been  advised  and  practiced 
as  a  substitute  for  the  ligature  of  the  primitive  vessel.  The  lead- 
ing argument  in  its  favor  is  that  thus  the  encephalic  circulation 
not  being  interfered  with,  the  danger  of  cerebral  complication  is 
avoided. 

The  cutaneous  landmark  for  finding  this  artery  has  been 
given:  it  is  a  continuation  of  that  for  reaching  the  common 
carotid,  viz.,  the  upper  third  of  a  line  drawn  from  the  sterno- 
clavicular joint  to  the  fossa  behind  the  lobulus  of  the  ear. 
Writers  are  not  in  accord  as  to  the  ease  or  difficulty  with  which 
the  external  carotid  can  be  displayed  for  ligation.  Allan  Burns 
says  that  "it  is  much  easier  to  pass  a  ligature  around  the  exter- 
nal carotid  artery  than  eitlier  the  internal  or  the  common  carotid 
artery:  for  both  the  latter  are  in  contact  w^ith  large  nerves  and 
the  internal  jugular  vein."  Chelius  says:  "Tying  the  external 
carotid  artery  is  considered  one  of  the  most  difficult  operations, 
on  account  of  the  vessel  being  surrounded  with  arteries,  veins 
and  nerves:  and,  therefore,  it  is  usually  recommended  to  tie  the 
common  trunk  instead  of  it."  It  was  tied  first  in  1827,  b}' 
Bushe,  for  the  arrest  of  haemorrhage  which  followed  the  excision 
of  an  anastomotic  aneurism  located  in  the  temporal  region. 
And  as  a  prophylactic  precaution  against  the  loss  of  blood  in  the 
removal  of  growths  seated  in  the  n?axillary  or  cervical  region, 
the  artery  was  ligated  by  Mott,  Lizars  and  other  surgical  opera- 
tors. The  manner  of  reaching  and  displaying  the  vessel  for 
ligation  was  first  accurately  described  by  Diedrich,  in  1831.  His 
incision  consists  of  a  cut  tiirough  the  skin  which  is  a  half  inch 
inside  of  the  inner  margin  of  the  sterno-cleido-mastoid  muscle, 
and  which,  commencing  on  a  level  with  the  upper  margin  of  the 
thyroid  cartilage,  ends  above,  a  little  below  the  inferior  margin 
of  the  lower  jaw.  If  the  wound  be  dilated  by  retractors,  the 
sterno-cleido-mastodd  will  be  seen  on  the  outside,  the  corner  of 
the  hyoid  bone  on  the  inner  side,  the  sub-maxillary  gland  in 
the  upper  angle,  and  the  omo-hyoid  muscle  at  the  lower  end. 
As  the  dissection  penetrates,  there  will  be  reached  the  thyroid, 
lingual  and  facial  veins,  which  converge  and  uniting  form  a 
trunk  of  considerable  magnitude,  which  passes  to  the  internal 
jugular  vein.  This  vessel  will  bleed  profusely  if  opened;  and,  if 
it  is  necessary  to  divide  it,  it  should  first  be  doubly  tied  and  di- 
vided between  the  ligatures. 

The  depth  to  which  the  dissection  must  proceed  before  reach- 
ing the  vessel  varies  in  the  obese  and  emaciated  subject:  in  the 


1122  VKSSKLS    OF    THK    NECK. 

latter,  the  vessel  is  near  the  skin;  but  the  distance  may  be  an 
inch  in  a  subject  of  short,  thick  neck,  laden  with  adeps.  And 
these  conditions  determine  the  facility  or  difficulty  of  the  work  : 
nothing  in  the  list  of  ligations  can  be  easier  tlian  the  one,  and 
notliing  more  difficult  than  the  other:  lience  arise  the  discord- 
ant statements  about  tliis  matter. 

The  dissection  having  penetrated  to  the  internal  and  external 
carotids,  how  may  these  be  distinguisljed?  The  external  carotid 
lies  anterior  to  the  internal  one;  that  is,  the  external  carotid  is 
nearer  the  median  line  of  the  neck  than  is  the  internal  one. 
Between  the  two  there  is  but  little  appreciable  difference  in 
magnitude.  The  best  differentiating  means  is  the  fact  that 
vessels  arise  from  the  external  one,  while  normally,  no  branches 
spring  from  the  internal  carotid.  In  exceptional  cases  vessels 
have  been  found  to  proceed  from  the  internal  carotid:  viz., 
vessels  which  should  arise  from  the  external  vessel.  Again,  the 
common  carotid,  in  a  case  seen  by  Allan  Burns,  and  in  one  seen 
by  the  writer,  ascended  almost  to  the  base  of  the  skull  before  it 
bifurcated:  and  then  the  branches  which  normally  originate 
from  the  external  carotid,  arose  from  the  primitive  carotid. 
Such  knowledge  of  anatomical  anomalies  should  be  stored  in  the 
memory  of  the  surgeon  who  would  be  read}'  to  meet  every 
emergency  which  his  knif#  may  encounter  in  operating  on  the 
neck.  The  general  rule  is  that  the  blood-supply  to  the  side  of 
the  neck,  tongue,  face  and  temporal  region  is  from  tlie  branches 
of  the  external  carotid;  and  hence  the  latter  is  named,  some- 
times, the  facial  carotid. 

The  numerous  branches  given  off  by  the  external  carotid  led 
to  the  belief  that,  if  tied,  the  vessel  would  not  become  occluded, 
and,  hence,  that  such  tying  would  end  in  secondary  haemorrhage. 
Guyon's  researches  and  work  in  this  field  showed  that  such  fear 
was  groundless  ;  and  Madelung,  on  the  same  subject,  collected  a 
series  of  sixty  ligations,  of  which  thirteen  died:  and  of  the  fatal 
cases  Madelung  sliowed  that  death  in  seven  patients  Avas  not 
caused  by  the  ligation.  The  writer  has  done  this  ligation  seven- 
teen times,  and  all  ended  favorably  except  one,  in  which  death 
arose  from  cerebral  trouble  caused  by  ligating  the  primitive  carotid 
on  the  other  side.  In  only  one  i)atient,  elsewhere  referred  to,  did 
secondary  bleeding  take  place;  and  to  arrest  this,  the  common 
trunk  was  ligated.  A  few  days  afterwards  there  was  another 
profuse  haemorrhage  from  the  original  wound,  which  was  con- 
trolled by  a  piece  of  aseptic  sponge  crowded  into  the  wound,  and 


LIGATIOX    OF    THE    EXTERNAL    CAROTID    ARTERY.  1123 

retained  there  by  digital  compression.  This  sponge  was  occa- 
sionally replaced  by  a  new  one;  the  compression  was  continued 
until  the  wounded  vessel  was  closed  and  the  patient's  recovery 
insured. 

The  vessel  having  been  reached,  it  should  be  so  displayed  as 
to  present  the  thyroid,  lingual  and  facial  branches  wdiich  arise 
from  its  anterior  side;  and  the  ligature  may  then  be  placed  in 
the  space  between  the  first  and  second,  or  between  the  second 
and  third  of  these  vessels :  as  a  rule,  there  is  the  most  room 
between  the  thyroid  and  lingual  branches.  Should  the  space  be 
short,  as  may  be  in  a  subject  of  short  neck,  then,  as  the  author 
did  in  one  case,  besides  the  external  carotid,  the  superior  thyroid 
artery  may  be  tied,  also.  Thus  the  formation  of  an  occluding 
clot  is  insured. 

After  the  exposure  of  the  vessel,  should  another  point  appear 
more  favorable  for  applying  the  ligature  than  the  one  just  indi-' 
cated,  then  the  work  should  be  done  there:  the  rule  for  observ- 
ance being  to  place  the  ligature  as  far  as  practicable  from  a 
branch,  or  branches,  which  would  interfere  with  the  formation  of 
an  occluding  thrombus. 

The  ligature  having  been  placed  and  the  cord  cut  short,  the 
wound  is  to  be  closed  and  treated  in  the  same  manner  as  that 
detailed  for  the  ligation  of  the  primitive  carotid. 

Certain  branches  of  the  external  carotid  are  sometimes  tied: 
and  those  in  which  this  is  chiefly  practiced  are  the  superior 
thyroid  and  the  lingual  arteries. 

The  superior  thyroid  is  sometimes  ligated  as  an  antecedent 
step  to  removal  of  the  thyroid  gland :  also,  as  a  means  to  arrest 
the  growth  and  induce  atrophy  of  the  enlarged  thyroid  gland. 
The  method  proposed  by  Linhart,  of  Munich,  to  find  the  vessel  is 
to  expose  the  external  carotid,  and  then  tie  the  first  branch  which 
is  given  off.  And  in  the  same  way,  he  would  search  for  the 
lingual  artery,  which  is  the  second  branch  given  off  from  the  inner 
side  of  the  external  carotid.  The  author  has  already  given  a  rule 
for  finding  the  lingual:  but  in  case  the  operator  loses  his  way,  or 
from  any  cause  becomes  embarrassed  in  his  search,  then  he  may 
follow  the  method  of  Linhart  for  finding  the  lingual.  To  elimi- 
nate all  uncertainty,  when  the  method  of  Linhart  is  practiced,  the 
incision  should  be  long  enough  to  expose  the  bifurcation  of  the 
common  carotid:  otherwise,  error  can  arise  in  the  enumeration 
of  the  branches  given  off  from  the  external  carotid;  for  example, 
the  lingual  miglit  be  mistaken  for  the  facial,  or  superior  thyroid. 


1124  VESSELS   OF   THE   NECK. 

but  if  tho  bifurcation  bo  found,  then  the  first  brunch  above  must 
be  the  superior  thyroid,  and  the  second  branch  the  lingual. 

•Should  the  internal  carotid  be  the  one  which  it  is  intended  to 
ligate,  then  a  cut  is  to  be  made  similar  to  that  for  the  external 
carotid:  the  dividing  i)oint  of  the  common  carotid  into  its  two 
branches  must  be  sought  for;  and  when  found,  the  posterior 
branch  will  be  the  internal  carotid,  which  is  close  to,  and  i)artly 
covered  on  its  outer  side  by  the  internal  jugular  vein.  From  the 
proximity  of  the  internal  carotid  to  the  external  caroti'd  on  one 
side,  and  to  the  internal  jugular  on  the  other,  it  is  a  difficult  act 
to  pass  the  aneurismal  needle  underneath  it:  and  as  prelude,  the 
external  carotid  must  be  detached  and  drawn  inwards,  and  the 
internal  jugular  detached  and  drawn  outwards;  and  for  this 
work  blunt  hooks,  or  small  retractors,  should  be  used.  The 
internal  carotid  has  very  intimate  relations  with  the  sympathetic 
nerve,  which  forms  a  sheath-like  plexus  about  the  arter}':  and 
this  nervous  structure  should  not  be  included  in  the  ligature. 
Besides  the  obstacles  enumerated,  the  operator  will  find  some 
trouble  in  uplifting  the  vessel ;  for  the  writer's  experience  in  this 
work  has  shown  him  that  the  artery  is  rigidly  stretched  between 
the  primitive  trunk  and  the  bony  canal  through  which  it  enters 
the  petrous  portion  of  the  temporal  bone.  Nevertheless,  despite 
these  difFiculties,  by  patient  effort,  the  ligature  can  be  passed  and 
the  tying  done.  Owing  to  the  rigidity  of  the  artery,  in  tightening 
the  ligature,  care  must  be  used  not  to  cut  or  break  the  vessel. 

The  ligation  of  the  internal  carotid  can  cause  cerebral  dis- 
turbance in  the  same  manner  as  ligation  of  the  common  trunk, 
already  mentioned;  but  as  there  is  an  intercommunication 
between  the  external  and  internal  carotids  in  the  orbit,  the 
chances  of  restoration  of  the  circulation  after  tying  the  internal 
carotid  must  be  better  than  after  the  ligation  of  the  primitive 
trunk.  The  difficulties,  however,  which  beset  the  operator  in 
reaching  the  internal  carotid  are  so  great  that  it  is  not  probable 
that  this  ligation  will  supersede  that  of  the  prime  trunk:  cer- 
tainly not  in  the  subject  of  short,  thick  neck,  in  which  the 
internal  carotid  is  very  short. 

The  marvelous  progress  which  has  been  made  elsewhere  in 
operative  work  has  also  extended  to  the  cervical  region;  and 
arteries  which  hitherto  had  been  exempt  from  interference,  have 
recently  become  the  occasional  subject  of  ligation.  An  example 
of  such  operation  is  the  tying  of  the  vertebral  artery. 

The   vertebral   artery,  as   will   be   remembered,  is   the  first 


LIGATION    OF    THE    EXTERNAL    CAROTID   ARTERY,  1125 

branch  given  off  from  the  subclavian,  and,  a  variable  distance 
beyond  its  origin,  the  vertebral  enters  an  interrupted,  bony  canal 
which  traverses  the  transverse  processes  of  the  six  upper  cervical 
vertebrae;  that  is,  all  of  these  vertebrse  except  the  seventh  ;  then 
the  vessel  enters  the  foramen  magnum,  and  becomes  one  of  the 
four  vessels  which  furnish  blood  to  the  brain.  From  the  basilar 
prolongation  of  the  confluent  vertebral  arteries  emanate  the  pos- 
terior cerebral  arteries,  which  aid  in  forming  the  circle  of  Willis  : 
and,  as  has  already  been  pointed  out,  one  of  the  posterior  commu- 
nicating branches,  which  connect  the  posterior  cerebral  arteries, 
may  be  very  diminutive:  so  much  so  as  to  be  an  obstacle  to 
restoration  of  the  circulation  after  ligation  of  the  vertebral,  or  the 
common  carotid  artery. 

The  aid  of  the  surgeon,  as  before  stated,  has  recently  been 
invoked  in  the  treatment  of  epilepsy ;  and,  besides  the  ligation  of 
the  common  carotid,  or  the  internal  carotid  artery,  the  tying  of 
the  vertebral  artery  has  lately  been  advised  and  practiced,  as  a 
means  of  curing  this  disease.  In  regard  to  the  value  of  this 
procedure  experience  has  not  yet  pronounced  its  verdict.  But 
as  the  "Comitial"  disease  usually  begins  in  childhood,  and, 
according  to  the  Hippocratic  aphorism,  may  vanish  before 
puberty,  hence  in  that  period  of  life  many  remedies  acquire  the 
credit  of  curing;  but,  after  twenty-five  years,  the  disease,  as  a  rule, 
only  "dies  with  the  patient,"  and  durnig  this  period,  epilepsy 
seldom  surrenders  to  ligature  or  trephine. 

The  more  usual  purpose  for  wdiicli  the  vertebral  is  tied  is  to 
control  hsemorrhage  from  the  wounded  vessel :  and  such  hsemor- 
rliage,  as  well  as  its  control  by  ligature,  has  been  studied  by 
Kocher,  who  has  collected  twenty-one  cases,  one  of  which  he 
treated  himself.  In  his  case  there  had  been  a  stab  which  had 
penetrated  about  one  inch  outside  of  the  median  line  of  the  neck, 
in  the  region  of  the  fifth  or  sixth  cervical  vertebra.  After  three 
weeks  of  constant  bleeding,  he  cut  down  and  sought  for  the  ves- 
sel; the  proximal  end  of  the  vertebral  was  caught  and  tied,  while 
the  return  of  blood  from  the  distal  end  was  controlled  by  tam- 
poning with  a  styptic  plug.  The  patient  recovered,  though  an 
attack  of  erysipelas  occurred  during  the  treatment. 

There  is  difficulty  in  distinguishing  whether  such  a  wound 
has  opened  the  vertebral  or  carotid  artery:  for  compression  on 
the  tubercle  of  the  sixth  vertebra,  presses  both  on  the  carotid 
and  vertebral  artery:  and  to  accurately  discriminate,  one  must 
make  pressure  from  without  inwards,  testing  each  part  in  sue- 


1126  VESSELS    OF    THE    NECK. 

cession.     The  carotid  is  best  compressed  by  including  it  along 
with  thesterno-cleido-mastoid  muscle. 

The  vertebral  artery  is  only  open  for  ligation  for  a  little  over 
two  and  a  half  inches:  viz.,  from  its  origin  to  its  entrance  into 
the  sixth  cervical  vertebra. 

The  Hunterian  ligation,  which  is  not  advised  by  Kocher,  is 
made  by  a  cut  along  the  outer  side  of  the  sterno-cleido-mastoid. 
In  case  of  a  wound  of  the  vertebral,  he  prefers  the  old  plan  of 
Anthyllus,  in  which  a  cut  is  made  down  on  the  wound,  and  the 
ends  there  ligated. 

Fracy,  in  1847,  writing  on  ligation  of  the  vertebral,  advises  to 
make  a  cut  upwards,  from  the  sterno-clavicular  articulation  on  the 
inner  side  of  the  sierno-cleido-mastoid  muscle,  and,  when  the 
vascular  group  is  found,  it  is  to  be  drawn  outwards  along  with 
the  overlying  muscle:  then  the  vertebral  artery  will  be  found  in 
the  triangle  between  the  scalenus  auticus  and  longus  colli  mus- 
cles. Tie  one  inch  belo\v  the  carotid  tubercle.  In  this  work,  the 
inferior  thyroid  artery  and  the  sympathetic  nerve  are  endangered. 

In  1867,  Gherini  wrote  on  wounds  of  the  vertebral  artery, 
from  a  collection  of  ten  cases;  and  he  finds  it  hard  to  decide, 
in  penetrating  wounds  in  this  region,  whether  the  carotid  or  ver- 
tebral artery  be  wounded.  He  finds,  also,  that  aneurism  of  the 
vertebral  artery  has  usually  been  mistaken  for  that  of  the  ca- 
rotid; and  the  mistake  has  been  made  of  tying  the  latter;  and  as 
treatment,  Gherini  would  first  try  compression,  and,  this  failing, 
he  would  endeavor  to  tie  the  vertebral. 

Gherini's  plan  is  to  circumscribe  the  artery  by  means  of  a 
thread  passed  between  two  of  the  transverse  processes  through 
which  the  artery  passes;  a  serious  objection  to  this  is,  that  impor- 
tant parts,  as  nerves,  might  be  included  in  the  ligature.  Others, 
again,  have  simply  stitched  up  the  w^ound  ;  but  this  plan  is  faulty, 
since  the  opened  artery  would  continue  to  pour  out  its  blood  into 
the  tissues,  and  produce  a  false  aneurism.  Kocher  finds  that 
some  cases  have  been  cured  by  simple  compression  on  the  wound, 
while  the  head  is  maintained  at  rest. 

The  mode  of  ligating  the  vertebral  artery  as  prescribed  by 
Farabeuf,  is  as  follows:  first  seek  the  carotid  tubercle  of  the 
sixth  cervical  vertebra,  which,  according  to  Chassaignac,  becomes 
unduly  prominent  and  distinguishable,  through  the  effacement 
of  the  anterior  tubercle  of  the  seventh  vertebra  by  the  action  of 
the  vertebral  artery  that  rests  on  it:  and  immediately  below  this 
tubercle   is  the   artery.     Incise   along   the  outer  border  of  the 


SUBCLAVIAN    ARTERY.  1127 

sterno-cleido-mastoid  muscle,  similarly  to  the  cut  made  for  find- 
ing the  carotid  artery.  When  the  vasculo-nervous  group  of 
structures  is  found,  pull  them  inwards,  when  the  vertebral  artery 
will  be  seen  and  the  ligature  can  be  passed  around  it. 

Albert  of  Vienna,  writing  in  1881,  says  the  ligation  of  the 
vertebral  is  very  difficult,  and,  till  that  time,  had  onl}^  been  tied 
three  times.  To  do  the  work,  make  an  incision  on  the  outer 
margin  of  the  sterno-cleido-mastoid,  from  the  point  where  the 
external  jugular  vein  crosses  the  muscle  to  the  clavicle.  This 
cut  is  about  two  inches  long.  If  the  vein  is  in  the  way,  it  may 
be  tied.  The  sterno-cleido-mastoid  muscle  and  the  vessels  and 
nerves  are  to  be  caught  with  a  retractor,  and  drawn  towards  the 
trachea.  At  this  point  it  will  be  of  aid,  if  the  head  which  was 
previously  bent  backwards  be  bent  forwards.  The  carotid 
tubercle  which  lies  about  three  fingers'  breadth  above  the  clavi- 
cle, is  next  to  be  found.  The  artery  is  now  to  be  ligated  below 
this  eminence;  and  the  vessel  lies  there  somewhat  inwards, 
between  the  insertions  of  the  scalenus  anticus  and  longus  colli 
muscles.  The  vertebral  vein  lies  on  the  outside  of  the  artery, 
and  in  throwing  the  ligature  around  the  latter,  the  vein  must  be 
pulled  outwards.  Instead  of  doing  the  work  thus,  one  may  do  as 
Maisonneuve  did,  viz.,  make  the  incision  on  the  inner  side  of  the 
sterno-cleido-mastoid  where  both  the  vertebral  and  inferior 
thyroid  arteries  may  be  tied. 

To  compress  the  vertebral  artery,  Fracy  directs  to  make 
pressure  on  the  lower  part  of  the  neck,  against  the  carotid  tuber- 
cle; such  compression  acts  both  on  the  carotid  and  the  vertebral 
artery.  If  compression  be  made  higher  up,  then  the  common 
carotid  only  is  acted  on;  this  was  proven  by  Fracy  by  injecting 
into  the  aorta  during  pressure  made  separately  on  each  of  the 
two  points;  in  the  case  of  pressure  made  low  down,  the  injected 
material  did  not  enter  either  carotid  or  vertebral ,  but  when  made 
above  the  carotid  tubercle,  the  material  only  enters  the  vertebral 
artery. 

Subclavian  Artery. — A  great  part  of  the  subclavian  artery  is 
situated  in  the  lowermost  portion  of  the  anterior  cervical  region. 
Functionally,  this  artery  ranks  with  the  most  important  vessels 
of  the  body;  through  the  two  subclavians  nearly  one-half  of  the 
blood  supply  to  the  brain  is  furnished;  and  the  upper  extremity 
derives  its  blood  through  the  same  channel.  The  right  and  left 
subclavian  arteries  differ  from  each  other;  the  right  springing 
from  the  innominate  is  shorter,  and  more  superficial  than  the 
left  artery. 


1128  VESSELS    OF    THE    NECK. 

For  convenience  of  description  and  guidance  in  operative 
work,  the  surgical  anatomist  maps  off  the  course  of  the  vessel  into 
three  sections:  the  first  of  these  extends  from  its  origin  to  the 
inner  border  of  the  scalenus  anticus  muscle;  the  second  portion 
lies  between  the  anterior  and  posterior  scalene  muscles,  and  is 
the  shortest  section  of  the  three;  and  the  tliird  and  torniinal 
section  extends  from  the  inter-scalene  space  to  the  lower  border 
of  the  first  rib,  where  the  vessel  becomes  the  axillary  artery. 

The  ligation  of  the  subclavian  artery  has  been  done  for  three 
purposes:  to  control  bleeding  when  the  artery  lias  been  wounded; 
for  the  cure  of  axillary  aneurism,  and  in  Brasdor's  and  Ward- 
sop's  operation  for  relief  in  aneurism  of  the  innominate  artery. 
It  should  be  done  as  a  preliminary  step  in  the  amputation  of  the 
humerus  with  the  scapula.  The  author  has  tied  the  vessel  twice 
in  cases  of  innominate  aneurism,  and  twice  for  the  cure  of 
axillary  aneurism. 

In  case  of  stabbing  wounds  of  the  vessel,  or  of  fracture  of  the 
adjacent  rib  or  clavicle,  in  which  a  fragment  has  pierced  the 
artery,  it  might  be  necessary  to  seek  tlie  vessel  and  ligate  it  on 
the  proximal  side  of  the  wound;  such  an  operation  would  be 
involved  in  great  difficulties;  for  tlie  structures  saturated  with 
ecchymosed  hlood  would  obscure  tiie  anatomical  landmarks,  so 
that  tlie  surgeon  would  be  forced  to  trust  to  touch,  rather  than 
to  sight. 

In  cases  of  aneurism  seated  in  the  axillary  artery,  ligation  of 
the  subclavian  has  been  done.  Early  in  this  centur}--  the  opera- 
tion was  attempted  by  Astley  Cooper  on  a  patient,  in  whom  the 
tumor  involved  a  part  of  the  third  portion  of  the  subclavian  :  the 
aneurism  so  uplifted  the  clavicle  that  this  celebrated  operator 
was  baffled  in  the  attempt  to  pass  a  ligature  around  the  vessel. 
Near  the  same  time,  in  1809,  Ramsden,  of  8i.  Bartholomew's 
Hospital,  tied  the  subclavian;  yet  the  patient  lived  but  six  days. 
These  pioneer  surgeons  found  much  trouble  in  passing  tlie 
ligature  around  the  vessel,  owing  to  the  want  of  an  instrument 
properly  constructed  for  the  purpose.  Invention  has  since 
remedied  this  in  furnishing  devices  which  easily  carry  the 
thread  around  the  vessel;  and  of  these,  one  of  the  best  is  that 
used  by  Valentine  Mott,  of  which  the  curved  point  can  be 
attached  and  detached,  and  the  thread  thus  carried  beneath  the 
vessel. 

The  ligation  is  most  easily  done  in  the  third  section  of  the 
artery;  and  if  the  work  cannot  be  done  there,  the  vessel  may  be 


SUBCLAVIAN    AKTERY.  1129 

sought  between  the  scalene  muscles  and  there  tied;  and  should 
approach  to  the  vessel  in  its  third  or  second  portions  be  imprac- 
ticable, then  the  work  may  be  attempted  in  the  initial  section  of 
the  artery. 

The  subclavian  artery  was  tied  in  the  first  part  of  its  course 
by  the  Irish  surgeon,  C.  Colles,  in  1813,  who  pronounces  the  feat 
not  difficult  on  the  right  side,  for  one  who  has  a  steady  hand,  and 
is  a  good  anatomist;  but  Colles  finds  it  far  otherwise,  on  the  left 
side;  here  it  may  be  declared  to  be  an  impossibile  undertaking. 
Here,  as  Colles  shows,  and  as  Hyrtl  indicates  in  greater  detail, 
the  left  subclavian  is  contiguous  to  the  vagus,  phrenic,  sympa- 
thetic and  inferior  laryngeal  nerves;  also,  the  thoracic  duct  is 
near  by,  and  likewise  the  apical  saccule  of  the  pleural  cavity. 
Danger  in  this  field,  as  elsewhere,  stimulates  to  daring:  and 
despite  the  deterrent  caution  of  Colles,  and  undismayed  by  the 
failure  of  others,  the  ligation  of  the  left  subclavian  in  its 
incipient  portion,  has  frequently  been  essayed,  and  properly,  too, 
the  author  thinks,  since  such  operation,  if  it  does  not  save  life, 
may  sometimes  prolong  it. 

The  subclavian  is  usually  tied  in  the  third  section,  beyond 
the  'scalene  muscles.  As  cutaneous  guide  to  find  the  vessel, 
Allan  Burns  directs  "to  draw  a  line  from  the  junction  of  the 
clavicle  and  coracoid  process  to  the  cleido  mastoid  muscle,  two 
inches  in  the  adult  above  the  sternum."  The  subclavian  lies 
below  this  line,  and  the  arteria  transversalis  colli  and  arteria 
cervicalis  superficialis  lie  above  it.  To  find  the  subclavian,  make 
an  incision  below  this  line,  parallel  with  and  above  the  clavicle, 
two  and  a  half  inches  long.  This  incision,  if  carelessly  made,  may 
cut  tlie  external  jugular  vein:  shun  this  "reef"  as  Farabeuf  calls 
it,  by  pulling  the  vein  aside.  To  best  display  the  artery,  let  the 
patient  lie  with  the  thorax  somewhat  uplifted,  and  the  shoulder 
of  the  side  to  be  operated  on  inclined  backwards.  An  aid  will 
assist  by  making  downward  traction  on  the  arm.  As  soon  as 
the  skin  is  opened  and  retracted,  and  the  external  jugular  placed 
in  safety,  the  work  advances  by  penetrating  through  a  mass  of 
adeps,  which  occupies  the  subclavian  triangle.  This  fatty  tissue 
is  loose  and  easily  opened.  As  a  rule,  the  operator  is  apt  to  seek 
too  near  the  upper  border  of  tlie  clavicle  for  the  artery.  At  this 
stage  of  the  work,  the  surgeon  is  solicitously  directed  by  the  topo- 
graphical anatomist  to  seek  for  the  scalene  tubercle,  on  the  first 
rib,  as  guide  to  the  vessel;  yet  from  the  writer's  experience,  the 
artery  is  usually  found  before  the  tubercle  is  discovered;  hence 
72 


1130  VESSELS   OF    THE   NECK. 

search  for  the  hitter  is  dispensable.  The  artery  having  been 
found  and  its  sheath  opened,  an  aseptic  silken  cord  is  to  be 
carried  round,  tied,  and  cut  short;  and  the  incision  being  sutured 
is  to  be  treated  as  an  ordinary  Avound. 

Should  the  conditions  contravene  ligation  in  the  third 
portion  of  the  subclavian,  the  next  best  site  is  where  the  artery 
lies  between  the  scalene  muscles;  and  this  may  be  done  by  an 
incision  similar  to  tlie  preceding,  if  the  cut  is  carried  fm-ther 
towards  the  median  line  of  the  neck.  The  fatty  layer  being 
opened  with  a  blunt  dissector,  the  anterior  scalene  is  found;  and 
lying  on  its  anterior  face  there  is  seen  the  phrenic  nerve,  a  small 
reddish  white  cord.  This  precious  structure  being  drawn  aside, 
the  muscle  is  next  divided,  and  the  artery  brought  to  view  and 
ligated.  Exceptionally,  the  subclavian  artery  lies  in  front  of  the 
anterior  scalene  muscle;  and  then  the  artery  and  subclavian 
vein  would  lie  side  by  side:  normally,  the  vein  lies  here  in  front 
of,  and  the  artery  behind  the  scalenus  anticus.  In  the  third 
portion  of  the  subclavian,  the  vein  lies  below  the  vessel,  and  is 
so  hidden  by  the  clavicle  that  the  operator  rarely  sees  it,  but  in 
the  first  and  second  portions  of  the  artery,  the  vein  is  closer  to 
the  vessel,  and  would  be  imperiled  by  careless  manipulation.* 

In  case  the  conditions  forbid  ligation  in  the  third  or  sec- 
ond portions  of  the  subclavian,  then  the  surgeon  should  seek 
and  tie  the  vessel  in  the  first  portion  of  the  artery;  and  the 
preceding  cut,  carried  to  the  median  line  with  division  of  the 
cleido  mastoid  muscle,  will  open  the  way  for  finding  the  vessel. 
The  deeper  work  must  be  done  with  the  blunt  dissector,  and, 
though  the  way  be  beset  with  dangers,  it  can  be  safely  traversed 
by  the  hand  which  has  acquired  steadiness  and  boldness  through 
hours  of  discipline  at  the  side  of  the  cadaver. 

Tlie  writer  has  ligated  the  subclavian  artery  four  times:  twice 
for  the  cure  of  aneurism  implicating  the  axillary  artery,  and  twice 
in  patients  of  innominate  aneurism,  in  which  tlie  right  carotid 
and  the  right  subclavian  were  simultaneously  tied.  In  all  these 
cases,  the  ligature  was  applied  to  the  third  or  terminal  portion 
of  the  artery.  Of  the  cases  of  axillary  aneurism,  one  recovered; 
in  the  other  case  secondary  hiemorrhage  occurred,  to  control 
wliich  the  artery  was  tied  in  the  first  part  of  its  course,  and  also 
retied  in  its  third  portion,  near  the  aneurism;  the  patient  died 
on  the  nineteenth  day. 

Of  the  cases  of  innominate  aneurism,  one  patient  survived  the 
ligation   but   one   week;  but   the   other  patient   recovered   and 


LIGATION    OF    THE    EXTERNAL   JUGULAR   VEIN.  1181 

resumed  his  business  as  watchman:  he  lived  but  six  months, 
death  being  caused  by  pulmonary  disease  which  was  indirectly 
induced  by  the  pressure  of  the  aneurismal  tumor  on  the  summit 
of  the  right  lung. 

Ligation  of  the  External  Jugular  Vein. — From  wounds  of  the 
external  jugular  vein,  there  may  be  so  much  bleeding  as  to 
require  ligation;  and  this  may  be  done  by  percutaneous  suture 
in  which  a  needle  armed  with  silk  thread  is  carried  through  the 
skin  and  platysma  myoid  muscle  beneath  the  vein,  so  that  when 
the  thread  is  tightened,  the  vein  is  included  with  a  portion  of 
the  skin.  And  such  a  ligature  should  be  double,  viz.,  one  on 
each  side  of  the  wound.  In  tliis  work  aseptic  thread  sliould  be 
used,  and  the  skin  well  cleansed  before  ligating.  On  the  fourth 
day,  the  thread  can  be  cut  and  removed. 

Sometimes  projected  surgical  work  on  the  neck  will  involve 
the  external  jugular  vein;  and  not  unfrequently  in  such  proposed 
work,  as  a  preliminary  act,  the  writer  has  resorted  to  percutane- 
ous circumscription  done  in  the  way  just  described,  above  and 
below  the  contemplated  wound.  The  superficial  venous  circula- 
tion of  the  front  of  the  neck  may  consist,  on  each  side,  of  an 
anterior  and  posterior  external  jugular  vein;  and  there  may 
even  be  a  third  vein  between  these  two.  This  increased  number 
of  veins  necessarily  lessens  the  calibre  of  each  vessel ;  thence  arises 
the  variability  in  the  caliber  of  the  external  jugular  vein.  The 
external  jugular  is  constituted  of  trunks  which  collect  the  blood 
from  the  temporal,  auricular  and  maxillary  regions;  these  trunks 
fuse  into  one  trunk  at  the  angle  of  the  jaw,  which  runs  thence 
on  the  side  of  the  neck  to  the  middle  of  the  clavicle,  where  it 
ends  in  the  subclavian  vein :  thus  its  course  traverses  the  field 
which  is  so  often  the  scene  of  operative  action.  If  this  work  is 
of  a  character  to  consist  only  of  longitudinal  incisions,  then 
the  external  jugular  vein,  as  wxll  as  the  anterior  and  median 
ones,  can  often  be  shunned  by  a  cut  which  lies  alongside  of  the 
vessel,  so  that  with  a  retractor  inserted  into  the  wound,  the  lip 
containing  the  vein  can  be  pulled  aside,  and  the  vessel  thus  left 
unopened.  But  should  a  transverse  incision  also  be  necessary, 
then  percutaneous  circumscription  may  be  resorted  to;  or  what 
the  writer  has  often  done,  the  vein  having  been  dissected  up  for 
a  short  space,  it  may  be  seized  with  two  pairs  of  forceps,  and 
divided  between  these;  and  then  each  end  is  to  be  twisted  on  its 
axis,  at  least  six  times.  Closure  being  thus  done,  air  cannot  enter 
the  vein,  as  has  been  recorded  to  have  occurred  after  wounds  of 


1132  VESSELS    t)F    THE    NECK. 

this  vessel.  The  aspiration  of  air  is  favored  in  cases  in  wliicli 
the  vein  is  unusually  largo;  and  also  when  in  the  o[)erative 
work,  the  lij)  of  the  transverse  wound  has  been  uplifted  so  as  to 
open  the  vein.  As  a  precautionary  measure  where  tlie  vessel  lias 
not  been  closed  by  torsion  or  circumscription,  tlie  surgeon  should 
direct  an  aid  to  maintain  compression  over  the  vein  on  the 
cardiac  side  of  the  wound;  that  is,  above  the  middle  of  the 
clavicle:  yet,  as  before  said,  it  is  always  safer  before  opening  tlie 
vessel  to  occlude  it  by  torsion  or  ligation. 

Wounds  of  the  luteiiial  Jugular  Vein. — When  the  internal 
jugular  has  been  opened  freeh',  the  resultant  bleeding  is  profuse; 
and  if  the  wound  has  been  made  by  the  surgeon  himself,  the 
scene  initiated  is  one  of  the  most  startling  emergencies  which 
can  arise  in  operative  work.  On  such  occasion  the  field  is 
instantly  inundated  with  a  wave  of  dark  blood,  that  fills  tlie 
wound  and  conceals  everything  tliere:  and  to  this  occurrence, 
(|uite  terrible  enough,  may  be  superadded  that  of  another  yet 
more  alarming,  viz.,  the  sound  of  air  inspired  into  the  wound. 
The  blood-wave  may  be  met  and  stayed  by  the  disciplined  hand 
of  the  surgeon:  but  the  air  aspirated  in  large  amount  penetrates 
to  the  heart  beyond  manual  reach,  where  it  may  speedily 
end  life. 

The  internal  jugular  is  often  endangered  in  the  removal  of 
the  tubercular  glandular  tumor  or  malignant  growths,  which  are 
adherent  to  the  vessel.  A  number  of  lymphatic  glands  lie  in 
chain  form  along  the  track  of  the  cervical  vessels;  and  they  are 
in  close  relation  with  the  veins.  As  result  of  this  contiguity,  the 
gland,  when  it  enlarges  and  inflames,  becomes  closely  connected 
with  the  vein,  and  may  involve  and  weaken  the  wall  of  the 
latter.  In  fact,  cases  are  recorded  in  which  the  venous  wall 
opened  and  the  cavity  of  the  gland  became  filled  with  blood. 
The  malignant  lymphoma  does  not  contract  adhesions  to  the 
vessels:  indeed,  a  thing  remarkable  in  the  removal  of  this 
growth  is  the  facility  with  which  it  may  be  enucleated  without 
disturbing  the  adjacent  vessel.  But  the  conditions  of  the  tuber- 
cular lymphatic  gland  are  far  different:  in  many  cases  the  sep- 
arktion  of  the  multiple  tumors  from  the  vessels  is  a  task  which 
tires  head  and  hand.  And  instead  of  complete  removal  of  the 
entire  gland,  the  knife  and  blunt  dissector,  near  the  conclu- 
sion of  the  work,  should  be  replaced  by  a  blunt  curette,  with 
which  along  the  line  of  danger  tlie  work  of  fragmentary  detach- 
ment can  be  pursued  a  little  further.     Since  the  introduction  of 


WOUNDS    OF    THE    INTERNAL   JUGULAR    VEIN.  1133 

iodoform  as  a  remedy  against  such  glandular  disease,  the  local 
use  of  this  agent  lessens  the  work  of  the  knife. 

In  cases  in  which  the  walls  of  the  vein  are  found  diseased,  or 
in  which  during  the  removal  of  a  tumor  a  laceration  of  the  vein 
is  unavoidable,  the  precautionarj^  step  should  first  be  taken  to 
tie  the  vein  at  two  points,  viz.,  above  and  below  the  part  that 
is  endangered.  The  ligation  of  the  vein,  whether  done  singlj- 
or  doubly,  as  here  advised,  is  free  from  danger:  in  fact,  as  the 
writer  has  repeatedly  verified,  no  inconvenience  arises  from  it, 
for  there  remain  intact  abundant  anastomotic  routes  through 
which  the  blood  can  reach  the  heart. 

Instead  of  removing  tubercular  glands  through  a  free  incision, 
the  work  is  sometimes  done  by  making  a  small  cut  to  the  diseased 
gland,  and  through  this,  reaching  and  scooping  out  the  affected 
structure.  Operating  in  this  blind  way  endangers  the  vein  much 
more  than  by  a  free  incision  and  exposure  of  the  part.  In  oper- 
ating thus  in  two  patients,  the  writer  has  had  the  misfortune  to 
lacerate  the  wall  of  the  vein,  and,  as  result,  to  have  caused  an 
unexpected  hEemorrhage  which  was  only  controlled  through 
ligation  of  the  vein  on  each  side  of  the  breach  in  its  wall. 

In  the  presence  of  such  a  wound  two  things  demand  imme- 
diate attention:  the  prevention  of  the  entrance  of  air  into  the 
wounded  vein,  and  the  arrest  of  haemorrhage.  The  entrance  of 
air  is  prevented  by  pressure  made  over  the  vein,  on  the  cardiac 
side  of,  and  close  to,  the  wound;  and  prophylactically,  such 
pressure  should  be  made  in  all  cases  in  which  there  is  a  proba- 
bility that  the  vein  may  be  opened.  To  arrest  the  haemorrhage, 
the  surest  means  is  to  tie  the  vein  on  each  side  of  the  opening; 
and  in  doing  this,  besides  compression  on  the  carotid  side,  pressure 
must  be  made  above,  or  on  the  peripheral  side  of  the  wound.  The 
pressure  on  the  peripheral  side  prevents  the  blood  from  reaching 
the  wound  and  disturbing  the  search  for  the  vessel;  and  when 
the  latter  is  found,  and  doubly  tied,  the  result  will  be  favorable,  as 
has  invariably  been  the  case  in  patients  so  treated  by  the  writer. 
In  this  double  ligation,  the  ligature  on  the  cardiac  side  guards 
against  the  inspiration  of  air  into  the  vein;  while  the  other 
ligature  prevents  further  bleeding.  Such  ligatures  should  be 
near  the  wound:  for  if  they  be  distant,  blood  might  still  reach 
the  wound  through  an  intercommunicating  vein. 

In  another  case  treated  by  the  writer,  during  the  removal  of 
a  glandular  tumor  which  was  attached  to  the  internal  jugular 
vein  where  it  commences  at  the  foramen  lacerum  posterius,  the 


1134  VESSELS    OF    THE    NECK. 

vein  was  torn  open,  foilowcd  by  a  ureat  gush  of  blood.  To  ligate 
on  the  cranial  side  of  the  wound  within  the  foramen  posterius 
was  impossible,  and  the  only  refuge  was  in  an  occluding  tampon. 
Such  a  tampon  was  devised  from  a  piece  of  sponge  rendered 
aseptic  by  alcohol,  and  was  pressed  down  to  the  wounded  vein 
and  held  there  b}"  the  finger.  This  occlusion  was  so  done  as  not 
to  interrupt  the  current  of  blood:  a  condition  necessary  for  the 
recovery  of  the  patient;  for,  had  the  venous  channel  been  whollv 
closed,  an  intra-cranial  thrombus  might  have  formed  and  closed 
the  lateral  sinus,  with  action  disastrous  to  the  integrity  of  the 
encephalon.  As  stated,  the  fenestra  in  the  vein  was  closed  by 
sponge  that  was  retained  in  site  by  pressure  of  the  index  finger 
of  a  trustworthy  nurse,  whose  hand  was  occasionally  relieved  by 
the  hand  of  the  patient.  This  work  was  continued  for  four  days 
and  nights  by  one  of  those  unsleeping  sentinels  which  it  is  the 
privilege  of  the  surgeon  to  occasionally  meet  as  a  second  in  his 
work.  For  such  service,  superhuman  endurance  and  self-sacrifice 
must  be  united. 

After  this  compress  had  been  kept  in  })osition  for  four  days, 
the  removal  of  the  sponge  was  commenced  by  carefully  loosen- 
ing its  outer  portion.  The  outer  part  so  detached,  gradually 
expanded,  and,  in  doing  so,  drew  on  the  part  which  lay  deeper 
in  the  wound.  In  this  way  the  tan:pon  was  latently  extracted; 
and  after  its  removal,  the  wound,  which  was  watched,  soon 
closed.  The  compression  here  mentioned  might  be  done  b}' 
some  tourniquet-like  device,  yet  a  nurse  of  proved  fidelity  would 
accomplish  the  work  .still  better,  since  finger  and  eye  would 
stand  watch  together. 

In  1867,  S.  W.  Gross  published  his  studies  upon  wounds  of 
the  internal  jugular  vein;  he  finds  such  injury  more  dangerous 
than  that  of  the  common  carotid:  since,  to  the  danger  of  ha3mor- 
rhage,  there  is  added  that  of  the  entrance  of  air  into  the  opened 
vein.  He  finds  no  recorded  case  of  recovery  after  a  gunshot 
wound  of  the  internal  jugular,  while  he  does  find  it  after  such 
wound  of  the  carotid. 

In  twenty  cases 'of  death  from  wounds  of  the  internal  jugular 
vein,  one-fourth  died  from  entrance  of  air  into  the  vessel,  one- 
fourth  from  primary  bleeding,  one-fourth  from  secondary  haem- 
orrhage, and  the  remainder  died  from  jivieniia. 

Arterio-venous  aneurism  was  seen  in  ten  patients  in  whom 
there  was  simultaneous  wounding  of  the  internal  jugular  and  the 
carotid  artery. 


WOUNDS    OF    THE    INTERNAL   JUGULAR    VEIN.  1135 

Gross  found  that  in  forty-one  cases  of  extirpation  of  cervical 
tumors  the  vein  was  opened,  and  tied;  and  of  those  so  treated, 
but  one  died.  Death  following  the  ligation  of  large  veins  usually 
occurs  from  secondary  bleeding. 

As  means  of  treatment  which  have  been  resorted  to,  are  com- 
pression and  ligation.  In  fourteen  cases  compression  controlled 
bleeding,  yet  this  is  painful  and  may  cause  suppuration.  In  some 
cases  treated  by  pressure,  though  secondary  haemorrhage  occurred, 
yet  under  a  continuance  of  this  treatment,  the  patients  were 
cured.  Complete  division  of  the  vein  diminishes  the  bleeding 
and  renders  it  easier  to  carry  out  compression. 

The  fear  of  awakening  phlebitis  has  deterred  from  ligation, 
yet  Malgaigne  declares  that  tying  the  internal  jugular  vein  is 
not  more  dangerous  than  that  of  the  carotid  artery.  Ligation  of 
the  internal  jugular  is  not  a  new  operation:  Thomas  Gale  writes 
that  it  was  done  in  the  sixteenth  century. 

Parietal  ligation,  done  by  Travers  in  1816,  on  the  femoral 
vein,  was  tried  by  "Wattmann  on  the  internal  jugular  vein;  the 
method  is  unsafe  and  has  been  discarded.  Instead  of  this  plan 
in  which  only  a  section  of  the  w^all  is  included,  the  proper  way  is 
to  tie  at  two  points  and  divide  between. 

In  wounds  of  the  internal  jugular  Langenbeck  tied  the  com- 
mon carotid.  The  peripheral  anastomosis  of  the  vein  and  artery 
do  not  justify  such  ligation;  and  Bardeleben  writes  that  he  saw  a 
case  in  which,  though  the  carotid  had  been  tied  to  control  bleed- 
ing from  the  wounded  internal  jugular,  yet  haemorrhage  from  the 
latter  was  not  controlled. 

When  a  vein  is  included  in  a  single  ligature,  Gross  finds  that 
it  becomes  closed  by  a  thrombus  on  the  distal  side,  while  the 
cardiac  side  is  closed  by  the  inner  tunic  adhering  to  itself. 

In  case  the  wound  were  in  the  lower  part  of  the  internal  jug- 
ular vein,  close  to  the  subclavian  vein  in  which  it  terminates, 
then  the  plan  of  treatment  which  suggests  itself  to  the  writer 
would  be  to  tie  the  vein  on  the  distal  side  of  the  wound,  and  then 
apply  an  aseptic  sponge  tampon  on  the  wound,  and  retain  this  in 
site  by  digital  or  mechanical  means. 

The  admission  of  air  into  the  opened  cervical  veins,  esjDecially 
the  internal  jugular,  has  been  mentioned:  and  as  it  is  a  matter 
of  much  gravity,  the  matter  merits  detailed  consideration.  In 
surgical  work  done  on  the  neck,  on  more  than  one  occasion  the 
writer  has  observed  slight  aspiration  of  air  into  a  wounded  vein; 
3^et  pressure  instantly  made  on  the  wound,  and  compression  on 


113G  VESSELS   OF    THE    NECK. 

the  cardiac  side  continued  during-  the  remainder  of  the  opera- 
tion, forestalled  further  trouble  which  otherwise  might  have 
occurred.  The  rai)idity  with  which  life  may  be  extinguished  by 
as[)irated  air  was  observed  by  the  author  in  a  man  from  whom  an. 
immense  giowth  had  been  removed  from  the  axilla,  and  when 
liealing  seemed  assured,  secondary  bleeding  occurred  from  the 
axillary  vein.  The  jiatient  being  nearly  moribund,  it  was 
decided  to  resort  to  transfusion;  and  as  no  i)roper  instrument 
was  at  hand,  a  common  syringe  was  used:  but  owing  to  the  haste 
which  the  occasion  demanded,  and  inaccurate  mani[)ulation  due 
to  inexperience,  when  an  amount  of  blood  had  been  injected 
into  the  axillary  vein,  probably  sufficient  to  rescue  life,  some  air 
Avas  admitted,  and  ended  life  as  quickly  as  could  be  done  by  an 
electric  stroke:  one  croaking  gasp,  and  life  was  extinguished. 

Death  from  entrance  of  air  into  the  veins  was  observed  and 
mentioned  by  Red i  in  1667;  and  early  in  the  present  century, 
death  from  this  cause  was  observed  in  dogs  who  had  been  the 
subjects  of  experiment.  In  1842,  there  were  recorded  several 
observations  of  death  thus  occurring  in  man.  Simon  mentions 
a  case  in  which  death  was  perilously  near  ensuing  from  the 
entrance  of  air  into  the  basilic  vein,  as  the  result  of  an  opening 
made  for  ordinary  bleeding. 

Various  explanations  of  the  way  in  which  death  is  thus  pro- 
duced, have  been  offered:  Marchal  maintained  that  through  the 
contact  of  the  admitted  air  with  the  blood,  carbonic  acid  is 
evolved  which  acts  as  a  toxic  agent.  Mercier  claims  that  the  air 
mingles  with  the  blood,  and  that  the  mixture  thus  formed 
becomes  an  elastic  one,  and  cannot  be  propelled  by  the  heart's 
walls,  but  regurgitates  into  the  veins:  and  further,  that  such  a 
compound  of  air  and  blood  cannot  pass  through  the  lungs,  even 
though  it  reach  these  organs. 

Wattmann,  also  in  1842,  wrote  on  this  subject.  He  finds 
that  air  is  apt  to  be  aspirated,  when  the  veins  are  rendered  tense, 
or  are  being  pulled  on  when  they  are  wounded.  Again,  when 
the  walls  of  the  vein  are  thickened  from  any  cause,  and  but 
partly  divided,  then,  during  inspiration,  air  is  apt  to  be  aspirated, 
especially  if  the  patient  is  erect.  When  such  accident  happens, 
it  is  announced  by  a  sharp  hissing  sound;  or  by  a  dull  gur- 
gling sound:  and  in  the  latter  case,  blood  and  air  are  commingled. 
The  patient  makes  a  sudden  outcry;  he  is  pale,  perspires,  and  may 
faint  or  be  thrown  into  convulsive  movements.  As  treatment, 
AVattmann  would  lower  the  head,  throw  water  on  the  face,  and 


WOUXDS    OF    THE    INTEKXAL   JUGULAR    VEIX.  1137 

give  stimulants.  He  does  not  approve  of  bandaging  the  chest, 
nor  the  sucking  out  the  air  with  a  tube,  nor  tracheotomy,  nor 
the  injection  of  fluids  into' the  veins:  means  advised  by  some 
authorities. 

In  1843  Erichsen,  writing  on  this  matter,  offers  the  opinion 
that  the  air  mixes  with  the  blood  and  forms  a  foam  which  cannot 
pass  through  the  lungs.  Elliott  claims  that  the  air  reaching  the 
heart  cannot  pass  beyond  it,  since  the  cardiac  valves  are  so  con- 
structed that  they  cannot  force  the  air  outwards,  but  when  it 
enters  the  right  ventricle  it  returns  again  to  the  auricle:  and 
thus  the  air  is  alternately  moved  backwards  and  forwards.  Also 
in  the  heart  the  air  expands  so  as  to  hamper  the  movement  of 
the  organ;  and  finally,  should  the  air  reach  the  lungs,  it  would 
be  cooled  there  and  forced  back  to  the  heart. 

Where  such  accident  is  feared  during  an  operation  Erichsen 
counsels  to  bandage  the  chest  so  that  a  deep  inspiration  cannot 
be  made.  And  in  a  patient  in  whom  such  accident,  has  occurred, 
he  would  lower  the  head  and  bandage  the  limbs,  so  as  to  force 
the  blood  to  the  nerve  centres. 

In  1850  in  the  removal  of  a  tumor  from  the  arm-pit  by  Gay, 
air  entered  a  vein  and  the  patient  fell  into  syncope  and  did  not 
rally  for  an  hour.  Lane,  who  was  a  witness  and  reporter  of  the 
accident,  claims  tliat  the  following  are  the  disposing  agencies  to 
such  aspiration:  deep  breathing  b}^  which  the  blood  is  moved 
towards  the  heart;  traction  on  a  vein  by  a  tumor,  or  by  an  over- 
lying muscle,  favors  the  entrance  of  air  into  the  vessel  when 
opened.  The  trapezius,  sterno-cleido-mastoid  and  the  platysma 
myoides  are  muscles  which  may  cause  such  traction. 

Poiseuille  taught  that  if  the  opening  in  the  vein  were  an  inch 
distant  from  the  thorax,  the  air  would  not  enter,  since  its  admis- 
sion would  be  prevented  by  the  pressure  of  the  external  air. 

iSfecropsy  after  death  from  this  cause  has  discovered  that  the 
left  ventricle  was  contracted,  while  the  riglit  side  of  the  heart, 
especially  the  right  auricle,  was  found  full  of  blood  mixed  with 
air;  also,  blood  mixed  with  air  was  found  in  the  pulmonary 
artery;  and  the  lungs  were  congested  and  contained  blood 
mingled  with  air.  Hence  death  is  from  asphyxia,  and  is  not 
from  the  friction  of  the  air  in  the  vessels  of  the  brain,  as  Bichat 
thought;  nor  is  it  from  palsy  of  the  heart,  or  the  i:)resence  of 
carbonic  acid  there,  as  others  have  taught. 

As  means  of  resuscitation.  Lane  recommended  stimulants, 
brisk  friction  of  the  skin,  and  artificial  respiration. 


1138  VESSELS    OF    THE    NECK. 

Couty,  of  Paris,  writing  iu  1S7G,  opposes  the  notion  that  the 
ill  effect  of  admitted  air  is  due  to  embolic  obstruction  of  the 
lungs:  he  thinks  that  death  is  caused  by  asystole  of  the  right 
heart,  resulting  from  the  presence  of  air  there;  and  as  final  result, 
death  ensues  through  suspension  of  the  pulmonic  circulation. 
The  action  of  admitted  air  is  classified  by  Cout}''  under  four 
heads:  (1)  diminished  aortic  pressure  and  increased  cardiac 
action;  (2)  aortic  pressure  still  more  diminished,  and  action  of 
the  heart  still  further  increased;  and  in  this  stage  the  conditions 
present  are  paleness,  syncope,  rapid  breathing,  and  dilated  pu{iils; 
(3)  blood  pressure  vanishes,  breathing  is  slow,  and  the  urine 
and  faeces  escape  involuntarily.  In  the  fourth  or  final  stage, 
there  is  cessation  of  breathing,  and  later,  cessation  of  the  heart. 

In  1876  Picard  experimented  on  animals  in  which  he 
admitted  air  into  the  portal  vein,  with  the  result  of  inducing 
hypertemia  in  the  rootlets  of  the  portal  system.  Besides  thi.?, 
the  heart's  action  was  increased,  and  the  respiration  was  rendered 
slower;  and  the  general  temperature  was  lowered. 

Fischer,  in  1877,  in  Yolkmann's  Klinische  Vortiage,  wrote  on 
this  matter.  He  had  observed  two  cases  in  which  air  was 
admitted,  and  yet  the  patient  recovered.  He  refers  to  Langen- 
beck's  advice  to  first  dissect  bare  the  vein  which  may  be  injured: 
this  cannot  always  be  done,  owing  to  a  tumor  lying  in  the  way; 
or  the  parts  may  be  diseased.  In  Fischer's  cases  recovery  took 
place  through  coughing,  which  forced  out  the  air  through  the 
wound;  and  hence  the  subject  of  such  accident  should  be  made 
to  cough,  sneeze  or  vomit:  for  thus  the  blood  is  forced  back  and 
out,  and  carries  the  air  with  it. 

Yivisective  experimentation  has  lent  its  aid  in  the  study  of 
the  aspiration  of  air  into  the  veins.  In  1859  and  18G0  Dr. 
E.  S.  Cooper  exhibited  before  a  class  of  medical  students  in  San 
Francisco  the  effect  of  throwing  air  into  the  veins.  The  femoral 
vein  of  a  dog  being  exposed,  a  tube  was  passed  into  it,  and  air 
was  forced  into  this  by  means  of  a  syringe.  The  dog  ceased  to 
breathe,  and  seemed  to  be  dead;  the  Jiandle  of  the  syringe  was 
then  drawn  back  and  blood  and  air  withdrawn,  with  the  effect 
of  restoring  the  dog  to  life.  He  never  had  an  opportunity  of 
applying  this  means  of  restoration  in  the  human  subject :  yet 
the  writer  thinks  it  might  be  done;  and  in  the  attempt  to  do  so, 
he  would  use,  if  possible,  the  vein  that  had  been  opened. 

In  Berlin,  in  1870,  some  experiments  were  made  by  Uterhart 
on  dogs,  in  v\'hich  he  injected  air  into  the  veins.     He  found  that 


CONGENITAL    DEFECTS    OF    THE   SPINAL    COLUMN.  1139 

when  the  air  was  introduced  into  a  vessel  remote  from  the  heart, 
as  for  example  the  crural  or  femoral  vein,  then  no  injury  resulted 
from  it:  but  if  the  air  was  injected  into  the  external  jugular 
vein,  then  death  quickly  ensued  under  symptoms  of  cerebral 
anaemia.  But  if  the  air  was  thrown  into  the  arteries,  no  ill 
resulted  to  the  animal,  no  matter  whether  the  point  of  injection 
was  near  or  remote  from  the  heart. 

CONGENITAL     DEFECTS     OP    THE     SPINAL    COLUMN    (SPINA    BIFIDA). 

A  congenital  deformity  not  unfrequently  seen  is  that  in  which 
the  arch  of  one  or  more  vertebrae  is  defective,  that  is,  the  arch  is 
bifid,  or  from  arrest  of  development,  the  spinous  process  has  not 
been  developed.  And  this  defective  formation  may  extend 
further  forwards:  in  fact,  to  such  an  extent  that  the  containing 
wall  of  the  spinal  canal  is  quite  wanting  behind,  and  at  the  sides. 
This  defect  occurs  much  oftener  in  the  lower  part  of  the  spinal 
column  than  in  the  upper  portion;  yet  it  has  been  observed  in 
the  region  of  the  atlas,  and  it  involved  the  occipital  bone.  And 
this  might  have  been  apprehended,  when  the  fact  is  recalled  that 
the  occipital  bone  in  its  growth  and  form  so  nearly  resembles  a 
vertebra,  that  tlie  bone  is  evidently  a  transformed  vertebra 
This  theory,  the  induction  of  a  Goethe's  fancy,  has  been  confirmed 
by  the  comparative  anatomist:  and  additionally  established  by 
the  observation  of  the  pathologist,  that  the  occiput  may  present 
an  opening  similar  to  that  of  a  bifid  vertebrse,  which  has  been 
imperfectly  developed. 

As  a  consequence,  or  accompaniment,  of  such  breach  in  the 
spinal  canal,  there  protrudes  through  the  opening  a  pouch-like 
tumor,  which  contains  a  fluid  similar  to  that  normally  existing 
in  the  spinal  canal.  This  fluid  is  always  contained  in  the 
meninges  of  the  cord:  but  in  relation  to  the  spinal  medulla,  the 
fluid  may  develop  within  the  primordial  central  canal  of  the 
cord,  and  so  increase  in  amount  as  to  ruj^ture  its  medullary  wall: 
and  then  the  normal  meninges  will  be  the  containing  tunic:  or 
the  fluid,  identical  with  that  of  the  cerebro-spinal,  may  lie  out- 
side of  the  cord,  and  be  contained  within  the  dilated  meninges. 

As  stated,  the  condition  of  the  cord  differs  according  to  the 
site  of  the  fluid:  when  originating  centrally,  the  cord  may  be 
attenuated  to  a  film-like  structure;  but  when  the  fluid  arises  and 
lies  eccentrically,  then  the  normal  integrity  of  the  cord  may  not 
be  altered. 


1140  VESSELS   OF   THE    NECK. 

There  may  result  serious  nervous  disturbance  from  the  cleft 
spine;  or  the  organism  may  suffer  but  little  from  it;  and  these 
differences  j)robably  depend  on  the  central  or  eccentric  site  of 
the  fluid. 

Though  much  oftener  in  the  lumbar  and  sacral  region  than 
in  the  upper  part,  yet  it  is  not  infrequent  in  the  cervical  region: 
two  cases  have  been  seen  l)y  the  writer  in  which  the  tumor  was 
large  and  was  located  in  the  region  of  the  fifth,  sixth  and  seventh 
vertebrie;  and  the  patients  had  reached  adult  age,  and  possessed 
average  strength  of  body.  The  spinal  cord  must  have  been 
intact  in  these  cases.  In  another  patient,  the  defect  was  in  the 
lumbar  region,  and  evidently  had  implicated  one-half  of  the 
cord,  since  one  limb  was  paralyzed,  ill  developed  below  the 
knee,  and  the  foot  was  in  the  position  of  varus.  And  should  a 
specialist,  whose  knowledge  does  not  extend  beyond  one  narrow 
angle  of  the  human  fabric,  attempt  to  correct  such  a  club-foot  by 
mechanical  appliance,  then  nature  would  avenge  such  blunder- 
ing by  extensive  sloughing.  In  such  cases  justice  unfortunately 
misses  its  aim,  and  the  forfeit  demanded  is  vicariously  paid  by 
the  guiltless  patient. 

Tiie  tumor  of  spina  bifida  may  have  a  wide  and  free  communi- 
cation with  tlie  spinal  canal;  that  is,  the  tumor  is  sessile,  and 
has  no  intermediate  connecting  foot-stalk;  or  there  maybe  a 
narrow  opening  into  the  canal;  and  then  the  tumor  is,  in  a 
manner,  pedunculated,  and  capable  of  being  isolated  from  the 
spinal  canal.  And  this  character  is  determined  by  the  brer.dth 
or  narrowness  of  the  osseous  vertebral  cleft;  for  when  the  spinal 
breach  is  wide,  the  tumor  rests  on  a  broad  base:  but  when  the 
opening  is  a  narrow  fissure,  the  base  of  the  tumor  may  be  so 
compressed  that  it  has  a  pedunculated  form. 

If  the  narrow  cleft  should  close,  then  there  will  remain  a 
cvst-like  tumor,  which  retains  its  volume  under  pressure:  but  in 
tijc  usual  form  of  spina  bifida,  pressure  on  the  tumor  lessens  its 
volume  by  forcing  the  liquid  content  into  the  spinal  canal;  and 
if  the  fluid  be  great  in  quantity,  then  reduction  of  the  tumor  will 
cause  symptoms  of  cerebral  compression ;  similar  to  what  takes 
place  when  pressure  is  made  on  the  protrusion  of  meningocele. 

The  diagnosis  is  not  difficult;  the  location  of  the  tumor  in 
the  median  line  behind,  its  reducibility  by  compression,  and  the 
effect  of  such  compression  on  the  subject  with  the  history  of 
congenital  appearance,  would  indicate  the  true  nature  of  the 
tumor.     And  the  withdrawal  of  some  of  the  fluid  by  the  aid  of 


CONGENITAL    DEFECTS    OF    THE    SPINAL    COLUMN.  1141 

a  hypodermic  needle  would  furnish  additional  proof  of  the 
nature  of  the  tumor,  and  would  distinguish  it  from  a  lipoma,  with 
which  it  is  possible  to  confound  spina  bifida.  The  lipoma  has  the 
characteristic  that  when  one  attempts  to  displace  the  skin  cover- 
ing it,  the  latter  becomes  mapped  off  into  quilted  sections 
corresponding  to  the  convolutions  of  tlie  lipoma;  but  in  spina 
bifida,  such  configuration  of  surface  is  absent. 

If  the  tumor  be  of  small  volume  and  pedunculated,  it  is 
curable:  but  if  it  be  voluminous,  with  large  communication  with 
the  spinal  canal,  the  attempt  to  relieve  encounters  many  diffi- 
culties. x4.nd  finally,  if  other  defect  coexist,  such  as  deformity  of 
the  face  or  head,  even  though  the  surgeon  remove  the  spinal 
tumor,  he  is  confronted  with  a  more  difficult  task  in  the  treat- 
ment of  the  other  deformities.  And  should  there  be  rhachischisis, 
or  cleft  of  the  cord,  complete  or  incomplete,  as  has  been  observed 
by  Koch,  then  the  case  will  not  lie  within  the  range  of  much 
amelioration  by  surgeon  or  physician.  But  if  the  defect  be 
confined  to  simple  spinal  meningocele,  the  case  may  be  improved 
or  cured  by  surgical  means. 

Treatment. — The  modes  of  treatment  may  be  placed  under 
four  heads:  compression,  obliterating  injection,  obstructive  con- 
striction, and  excision  and  closure  by  plastic  work. 

Compression  may  be  maintained  upon  the  tumor  either  by 
means  of  a  truss-like  appliance,  in  which  a  compressing  pad  is 
held  in  place  by  an  elastic  band  which  surrounds,  or,  in  some 
way,  clasps  the  body.  Such  compression  may  be  made  as  a 
means  of  protection  against  external  violence;  or  it  may  be  used 
as  a  means  of  cure.  As  a  protective  agent  the  compress  is  oftener 
used  in  the  adult;  but  it  may  be  used  in  the  infant  to  repress  the 
fluid  during  the  time  that  the  congenital  breach  is  gradually 
closing  during  the  growth  of  the  child.  The  hope  of  such 
occlusion  is  rarely  realized;  so  that  compressive  means,  when 
employed,  are  used  rather  for  the  purpose  of  protecting  the 
tumor  against  violence,  than  of  causing  its  disappearance. 

A  second  method  of  treatment  consists  in  the  injection  of 
some  irritating  agent  which  will  lessen  and  perhaps  finally 
occlude  the  cavity  of  the  tumor.  Such  agent  is  the  tincture  of 
iodine,  or  a  solution  of  the  chloride  or  sulphate  of  iron;  the 
former  has  been  most  frequently  used.  Brainard,  of  Chicago, 
reported  cures  effected  by  the  use  of  injection  of  iodine.  To' 
accomplish  occlusion  in  this  way,  the  tumor  must  have  but  a 
small  communication  with  the  spinal  canal,  which,  through  the 


1142  VESSELS    OF    THE    NECK. 

occlusive  action  of  tlie  injected  iodine,  will  be  closed,  and  then  a 
cyst-like  cavity  will  remain,  which  may,  also,  finally  become 
smaller,  and  disappear  througli  absorption.  This  plan  of  treat- 
raent  has  so  often  failed  that,  similarly  to  what  has  occurred  in 
hydrocephalus,  it  has  fallen  almost  into  disuse.  Its  use  should 
certainly  be  limited  to  those  cases  in  which  the  conformation  of 
the  tumor  is  such  as  to  be  easily  isolated  from  the  sjiinal  canal. 

A  third  method  of  treatment  is  like  that  once  in  vogue  for 
the  cure  of  umbilical  hernia:  it  consists  of  a  constricting  clamp 
which  having  included  the  base  of  the  tumor,  the  clamp  is  so 
tightened  as  to  interrupt  the  circulation,  and  cause  sloughing, 
and  consequent  destruction  of  the  tumor.  For  this  plan  to  be 
successful,  the  tumor  must  be  pedunculated,  or  capable  of  being 
isolated  from  the  adjacent  spinal  canal.  Chaffy,  in  1881, 
successfully  treated  a  case  in  this  manner;  and  as  constricting 
instrument,  lie  used  the  clamp  employed  by  Spencer  Wells  in 
ovariotom3\  Having  applied  the  clamp,  Chaffy  excised  the 
])art  beyond  and  then  let  the  clamp  remain  in  place  for  four 
days.     The  healing  was  by  granulation. 

A  plan  cognate  to  the  preceding  method  is  to  include  the 
neck  of  the  sack  in  a  subcutaneous  circumscribing  ligature, 
which,  being  tightened,  isolates  the  cavity :  and  when  the  isolation 
is  thus  complete,  the  part  beyond  the  ligature  may  be  excised. 

The  fourth  method  which  has  been  successfully  practiced  by 
the  writer  is  to  excise  a  portion  of  the  wall  of  the  tumor;  also 
dissect  from  the  remaining  wall  its  serous  lining;  and  then 
having  juxtaposed  the  raw  surfaces,  unite  these  by  suture. 

In  a  communication  read  at  the  recent  International  Medical 
Congress  at  Rome  by  Mayo  Robson,  of  England,  there  were 
reported  twenty  cases  treated  by  the  last  method,  with  such 
satisfactory  results  that  the  writer  urgently  advocates  the  pro- 
cedure. His  plan  consists,  in  the  main,  of  dissecting  the  serous 
sac  from  the  skin,  and  then  having  removed  the  excess  of  the 
sac  to  cljse  this  by  buried  sutures;  and  lastly,  so  close  the  skin 
that  the  buried  and  dermal  sutures  will  not  lie  one  on  the  other. 
Robson  finds  that  this  plan  may  be  successfully  employed  in  all 
cases  of  spina  bifida,  in  which  the  patient  is  not  hydrocephalous, 
paraplegic,  or  in  a  state  of  marasmus. 

In  a  case  of  spina  Ijifida  treated  by  the  writer,  the  base  of  the 
tumor  was  sutured  in  sections;  the  tumor  beyond  was  excised, 
and  the  remaining  wound  soon  healed  under  alcoholic  dressing. 
Hence  of  the  four  methods  of  treatment  described,  the  author 
prefers  that  of  simple  excision  and  closure  by  suture. 


CONGENITAL    DEFECTS    OF    THE    SPINAL    COLUMN.  1143 

Besides  the  bifid  cleft  described,  which  may  deform  the 
spine,  there  are  other  defects,  which,  though  rare,  should  be 
noted. 

One  or  more  vertebrae  may  be  imperfectly  developed;  and 
thus  lateral  or  antero-posterior  curvature,  or  deviation  of  the 
column,  may  arise.  Also  the  two  halves  of  a  vertebra  may 
remain  ununited;  whence  abnormal  mobility  may  arise. 

Should  such  defect  be  recognized,  the  surgeon  ma}^  use  a 
corrective  appliance,  designed  to  maintain  the  column  in  proper 
line:  and  as  examples  of  such  apparatus  may  be  cited  the 
orthopedic  appliances  employed  in  spinal  curvature. 

A  congenital  abnormity  sometimes  seen  in  the  lower  part  of 
the  neck,  is  an  elongation  of  the  transverse  process  of  the  seventh 
cervical  vertebra.  Or  this  process  may  be  transformed  into  a 
supernumerary  rib;  and  then,  as  Luschka  has  observed,  such 
costal  anomaly  may  be  a  fragmentary  rudiment,  consisting 
merely  of  a  head,  neck  and  tubercle;  or  it  may  extend  further 
forwards,  and  then  represent  a  false  rib,  at  the  upper  end  of  the 
thorax;  and,  lastly,  there  may  be  a  completely  formed  rib, 
attached  to  the  spine  behind  and  sternum  in  front. 

In  the  second  form,  in  which  the  rib  ends  b}^  a  free  point  in 
the  subclavian  triangle  a  little  above  the  clavicle,  the  terminal 
end  may  infringe  on  the  constituent  trunks  of  the  brachial 
plexus,  and  cause  pain  extending  along  one  or  more  of  the 
nerves  distributed  to  the  arm.  Such  anomalous  rib  might 
endanger  the  subclavian  artery  which  lies  in  contact  with  it. 
The  writer  has  seen  an  example  of  such  anomaly,  which  in  its 
development  was  impaled  or  imbedded  in  the  brachial  plexus, 
and  caused  severe  pain.  Relief  was  obtained  by  an  incision 
exposing  the  rib,  of  which  an  inch  of  the  free  end  was  excised. 
The  work  of  excision  was  difficult  and  perilous,  owing  to  the 
contiguous  subclavian  artery,  which,  with  much  difficulty,  was 
so  pulled  aside  as  to  permit  the  section  of  tlie  rib.  The  operation 
was  successful  in  delivering  the  patient  from  the  pains  in  the 
arm  with  which  she  was  previously  tormented. 


CHAPTER  XXXV. 


LUXATION  OF  THE  CERVICAL  VERTEBRA. 

Surgical  authorities  in  the  early  part  of  this  century  were 
united  in  the  opinion  that  isolated  vertebral  luxation  is  an 
impossibility.  Delpech  declared  that  dislocation  of  the  vertebral 
body  cannot  occur.  Abernethy  says,  "There  can  be  no  such 
dislocation,  surgically  speaking:"  or,  rather,  if  sucli  accident 
occurs,  there  must  be,  at  tl)e  same  time,  a  fracture.  Sir  Ashley 
Cooper  asserts  that  if  such  injury  ever  does  occur,  it  must  be 
extremely  rare;  and  in  tlie  numerous  instances  of  injury  of  the 
spine  which  he  had  seen,  he  had  never  observed  the  separation  of 
one  vertebra  from  another,  without  a  fracture  of  either  the 
articular  process  or  the  body  of  the  vertebra.  And  Boyer 
doubted  though  he  did  not  den}'  the  possibility  of  vertebral 
luxation. 

Since  this  period  of  skepticism  in  regard  to  vertebral  luxation, 
the  sphere  of  observation  has  widened,  and  thepossibility  of  such 
injury  has  been  verified  by  the  observation  of  tliis  luxation  in 
the  living  subject,  and  still  further  demonstrated  by  experimen- 
tation on  the  cadaver. 

In  1871  Stephen  Smith,  of  New  York,  made  experiments  on 
the  dead  subject,  in  which  fracture  and  luxation  in  the  region 
of  the  atlas  and  axis  were  studied.  He  finds  that  the  atlas 
belongs  fundamentally  to  the  head,  and  the  odontoid  process  of 
tlie  axis  is  the  center  of  the  movements  of  the  atlas  and  head: 
and  those  forces  wliich  act  from  the  head  on  the  spinal  column, 
and  those  from  the  spine  below  which  act  on  the  head,  are 
directed  towards,  and  are  exerted  on,  the  odontoid  process.  The 
alar  or  check  ligaments  which  extend  from  the  summit  of  this 
process  to  the  occipital  bone,  in  the  work  of  limiting  movement 
must  bear  much;  and  much  resistance  must  be  offered  by  the 
base  of  the  odontoid  i)rocess,  on  which  a  lever-like  force  is  exerted. 

Smith  concludes  that  when  a  person  falls  on  his  head,  the 

(1144) 


LUXATION    OF    THE    CERVICAL   VERTEBRAE. 


1145 


Tiolence  is  directed  against  the  alar  ligaments  and  the  base  of 
the  odontoid  process.  The  odontoid  process  must  support  more 
than  the  anterior  arch  of  the  atlas,  or  the  transverse  ligament. 
If  violence  be  applied  to  the  part,  the  axis  will  break  before  its 
odontoid  process;  and  this  process  does  not  break  when  it  is 
forced  against  the  anterior  arch  of  the  atlas,  or  the  transverse 
ligament.  The  alar  ligaments  have  more  strength  than  the 
odontoid  proces.^. 


Figure  108.     Exhibiting  com-  Figure  109.    Exhibiting  bilateral  lux- 

plete   antero-posterior    luxation.        ation.     (From  Albert.) 
(From  Albert.) 

Vertebral  luxation  may  be,  according  to  the  extent  and  char- 
acter of  the  injury,  divided  into  two  classes :  complete  and  partial. 
In  the  complete  form,  the  vertebra  has  its  articulating  facets  dis- 
placed entirely  from  their  normal  location:  and  the  displacement 
may  be  forwards,  or  backwards,  as  shown  in  figure  108.  In  the 
incomplete  form,  the  displacement  may  be  unilateral,  in  which 
the  luxation  is  backwards  or  forwards:  or  it  may  be  bilateral,  in 
which  the  vertebra  is  turned  about  its  vertical  axis,  with  luxation 
backwards  on  one  side,  and  forwards  on  the  other,  as  show^n  in 
figure  109.  ^ 

Along  with  vertebral  luxation  there  must  be  rupture  of  the 
inter- vertebral  ligaments:  and  that  such  rupture  may  occur, 
greater  violence  is  required  as  one  descends  in  the  column.  This 
fact  was  demonstrated  experimentally  by  Malgaigne,  on  the 
cadaver.  He  found  that  to  rupture  the  intervertebral  ligaments 
required  one  hundred  pounds  force  in  the  cervical  region;  one 
hundred  and  fifty  pounds  in  the  thoracic  region,  and  from  two 
hundred  and  fifty  to  three  hundred  pounds  in  the  lumbar  region. 
73 


1146  LUXATION    OF    THE    CERVICAL    VERTEBRAE. 

In  case,  liowever,  the  subject  be  an  old  one,  then  the  partial  or 
entire  ossification  of  the  connecting  ligaments  may  give  them  so 
much  resistance  that  fracture,  and  not  luxation,  ensues.  The 
elastic  ligaments  of  the  child  and  youth  permit  of  movements  at 
that  age,  which  cannot  be  made  in  later  life.  Long  continuance 
of  the  upright  position  temporarily  exhausts  the  elasticity  of 
these  ligaments;  hence  the  lessening  of  stature  of  him  who  has 
been  standing  for  many  hours. 

The  age  of  the  subject*  has  an  important  iuHuence  on  the 
occurrence  of  vertebral  luxation:  in  childhood,  and  prior  to 
complete  growth,  the  bones  are  not  fully  ossified  from  their  early 
cartilaginous  stage,  and  the  ligaments  are  extensible:  hence,  at 
this  period  of  life,  though  the  spine  is  often  subjected  to  violence 
from  accidental  or  voluntary  movement,  yet  luxation  or  fracture 
is  seldom  seen;  but  such  injury  is  seen  oftener  in  mature,  or 
advanced  age.  This  accords  with  the  experience  of  Porta,  who 
made  a  study  of  these  injuries. 

In  1865,  Porta  published  a  work  on  luxations  in  all  parts  of 
the  body,  comprising  a  series  of  five  hundred  dislocations,  of 
which  twenty-seven  were  of  the  vertebral  column:  and  of  the 
latter  seven  were  of  the  cervical  vertebrae.  An  important  diag- 
nostic distinction  which  he  indicates  between  luxation  and 
fracture  of  the  spine  is,  that  a  simple  fracture  leaves  no  percep- 
tible displacement  or  irregularity  in  the  outline  of  the  column: 
but  if  the  case  be  one  of  luxation,  there  is  evident  deformity.  In 
the  cases  seen  by  Porta,  the  subjects?  were  adults;  and  the  causal 
agency  was  a  blow,  or  a  fall.  He  finds  that  the  anterior  longi- 
tudinal ligament  is  stronger  than  the  posterior  one;  and  the 
intervertebral  disks  and  articular  ligaments  are  easily  torn.  The 
interspinous  ligaments  of  the  dorsal  region  are  so  strong  that 
unless  tlie  spinous  processes  are  broken,  the  ligaments  prevent 
displacement.  Hence  the  usual  coincidence  of  fracture  and  lux- 
ation. 

The  prognosis  of  luxation  in  the  cervical  region  is  unfavorable: 
for  death  can  occur  at  once,  on  the  receipt  of  the  injury,  or  at  an 
early  period,  from  acute  inflammatory  action;  or  the  case  may 
end  fatally  after  an  indefinitely  long  duration.  The  spinal  injury 
may  be  associated  with  other  complication  caused  by  the  lesion 
of  the  cord:  such  trouble  may  be  tetanus  or  encephalitis;  like- 
wise, sloughing  from  pressure  of  the  recumbent  body;  there  may 
also  be  vesical  atony  in  which  the  urine  is  retained,  or  is  voided 
involuntarilv. 


LUXATION    OF    THE    CERVICAL   VERTEBRA.  1147 

Though  death,  as  a  rule,  follows  such  luxation, yet  exception- 
ally, recovery  may  occur.  As  treatment,  Porta  does  not  favor  an 
operation;  but  on  the  contrary,  reduction  should  be  attempted 
by  extension  and  counter-extension;  and  means  designed  to 
limit  inflammation,  should  be  employed. 

Hueter,  in  1868,  from  his  personal  studies  offered  a  new 
classification  of  vertebral  luxation:  he  makes  two  classes  founded 
on  the  manner  in  which  the  causal  violence  acts;  luxation  from 
rotation  or  abduction,  in  which  the  dislocation  is  caused  by 
torsion  of  the  spine;  and  luxation  produced  by  flexion.  He  dis- 
cards the  terms  lateral  and  anterior  dislocation.  In  brief,  Hueter 
refers  all  spinal  luxation  to  violence  which  acts  by  twisting,  or  by 
bending  the  vertebral  column. 

The  spinal  cord  may  be  injured  by  the  displaced  vertebrae; 
yet  when  the  luxation  has  taken  place,  it  seems  that  the  primary 
pressure  gradually  lessens;  or  the  cord  acquires  a  tolerance  of  the 
compression.  As  consequence  of  the  injury  there  may  be  palsy 
from  pressure  on  the  nerves  where  they  emerge  through  the 
intervertebral  foramina. 

In  his  treatment  of  the  injury,  Hueter  does  not  approve  of 
the  methods  of  extension  and  counter-extension  which  are 
employed  by  Schuh,  Martin  and  others;  but  instead  of  these 
methods,  Hueter  advises  one  which  seems  to  have  originated 
with  Richet.  This  plan  consists  in  bending  the  head  towards 
the  shoulder,  towards  which  the  head  is  abnormally  directed :  that 
is,  towards  the  shoulder  of  the  side  on  which  the  chin  is  uplifted; 
and  when  this  is  done,  turn  the  head  so  that  the  ear  which  was 
inclined  towards  the  shoulder  shall  be  directed  forwards,  and  the 
other  ear  backwards.  This  plan  is  suited  for  reduction  of  the 
first  species  of  the  injury,  viz.,  that  arising  from  excessive  torsion; 
and  in  this  way  Hueter  accomplished  reduction.  But  if  the 
luxation  be  from  violent  flexion,  then  the  same  method  may  be 
resorted  to;  and  one  must  resort  to  it  on  one  side,  and  then  on  the 
other. 

Wagner,  in  1884,  from  the  study  of  two  hundred  cases  of  ver- 
tical luxation  which  he  found  in  surgical  literature,  published', 
the  following:  in  forward  luxation  the  head  is  not  always  bent 
directly  forwards:  there  is  no  definitely  typical  position.  And 
where  the  luxation  is  caused  by  excessive  rotation,  the  position  of 
the  head  differs  according  to  the  relative  position  of  the  dis- 
placed articular  processes.  When  unilateral  luxation  is  complete,, 
the  head  is  bent  towards  the  displaced  side,  and  the  chin  is  rotated 
towards  the  sound  side. 


1148        LUXATION  OF   THE  CERVICAL  VERTEBR.E. 

As  treatment,  Wagner  counsels  in  cases  of  incomplete  disloca- 
tion, simple  rest  and  fixation;  but  if  the  displacement  be  com- 
plete, then  he  would  try  to  reduce,  after  placing  the  patient  under 
chloroform. 

From  a  study  of  occipito-atloid  dislocation,  Malgaigne  has 
found  that  the  head  might  be  luxated  backwards,  or  the  atlas 
forwards.  The  atlas  may  be  so  tilted  forwards  as  to  greatly 
incline  the  head  forwards:  and  then  the  odontoid  process  may 
so  press  on  the  cord  as  to  cause  instant  death:  or  the  displace- 
ment forwards  of  the  atlas  may  be  yet  greater,  causing  more  or 
less  palsy;  and,  again,  the  atlas  may  be  rotated  on  one  side,  only. 
Where  the  atlas  is  luxated  forwards,  the  chin  is  caused  to 
approach  the  sternum;  but  if  the  displacement  be  unilateral 
and  has  arisen  from  torsion,  Malgaigne  found  the  head  inclined 
towards  the  luxated  side,  while  the  face  is  directed  towards  the 
sound  side.  In  these  high  luxations,  something  may  be  learned 
by  a  digital  examination  of  the  pharynx.  As  treatment  Mal- 
gaigne counsels  rest  in  the  horizontal  position;  and  in  the  worst 
cases,  he  would  attempt  to  reduce  by  flexion,  extension,  traction 
and  counter-traction. 

The  following  is  a  summary  of  the  })lans  of  treatment  which 
have  the  sanction  of  authority.  In  mild  cases,  which  may  be 
named  subluxation,  authorities  have  concurred  in  limiting  treat- 
ment to  rest  in  the  horizontal  posture;  but  in  more  extensive 
injury  in  which  the  dislocation  is  complete,  the  plan  has  gener- 
ally been  to  attemi)t  reduction  by  forcible  movement,  which  may 
be  done  in  one  of  the  following  directions:  extension  and  flexion; 
abduction  to  the  right  or  left;  rotation  to  the  right  or  left;  trac- 
tion and  counter-traction.  That  movement  in  each  case  should 
be  selected  which  will  act  correctively  on  the  existing  displace- 
ment. And  one  should  not  limit  this  manipulative  treatment  to 
cases  of  complete  dislocation,  it  should  also  be  tried  in  those  of 
subluxation. 

It  must  be  confessed  that  these  methods  are  not  exempt  from 
peril:  for  despite  the  most  diligent  diagnostic  exploration,  the 
exact  conditions  may  not  be  determinable  ;  and  then  the  manip- 
ulative procedure,  in  place  of  restoring  the  vertebra  to  proper 
position,  may  add  to  the  existing  displacement:  and  then  if  the 
injury  be  high  up,  fatal  injury  to  the  cord  inigiit  be  inflicted. 
The  deplorable  condition  of  such  patient,  deprived  as  he  is  of 
sensory  and  motor  power,  justifies  resort  to  a  hazardous  venture: 
for  to  the  victim  of  such  condition  death  is  better  than  life. 


LUXATION    OF    THE    CEHVICAL    VERTEBRAE.  1149 

A  resort  to  operative  work  as  a  means  of  relief  seems  to  have 
seldoin  beeu  tried:  jet  in  a  case  of  anterior  luxation  of  the  atlas, 
the  writer  availed  himself  of  this  method.     This  case   was  as 
follows:  from  a  fall,  the  jDatient  remained  with  fixation  of  the 
head,  and  with  the  chin  directed  forwards,  without  elevation  or 
depression.     "When  seen  the  condition  had  existed  for  nearly  a 
year:   the   man  was  unable  to  move  the   head,  the   eyes   were 
unduly  prominent:  the  power  to  form  articulate  speech  was  Yery 
defective;  there  was  partial  loss  of  motor  power  to  such  a  deo-ree 
that  the  patient  was  unable  to  walk  without  assistance.     There 
was  continued  pain  at  the  site  of  injury;  and  a  depression  could 
be  distinguished  beneath  the  occiput.     The  diagnosis  was  ante- 
rior displacement,  and  it  was  decided  to  cut  down  posteriorly, 
and  having  exposed  the  parts,  do  what  might  be  possible  for 
relief.     This  was  done :  through  a  vertical  incision  the  posterior 
portions  of  the  axis  and  atlas  were  brought  into  view.     The  atlas 
was  found  displaced  forwards  to  the  extent  of  a  quarter  of  an 
inch,  so  that  its  posterior  arch  was  crowded  against  the  cord.     It 
being  evident  that  an  attempt  at  replacement  would  be  fraught 
with   more   danger   than   prospect  of  relief,  it  was  decided  to 
remove  the  posterior  part  of  the  atlas,  which  was  done  by  divid- 
ing the  ring  on  each  side,  so  that  a  small  segment  could   be 
removed.     This  was  easily  done  with   bone  forceps.     After  the 
removal  of  the  small  bridge  which  was  crowding  on  the  cord,  the 
latter  at  once  rose  in  the  interstice,  as  if  it  had  previouslv  had 
insufficient  room.     This  work  was  done  without  any  lesion  of  the 
structures  within  the  canal;  and  as  soon  as  the  man  passed  from 
the  influence  of  the  ansesthetic,  there  was  found  some  improve- 
ment of  motor  power  in  the  arms  and  legs.     This  amelioration 
in  the  patient's  power  of  movement  was  followed,  a  few  days  after 
the  operation,  by  symptoms  of  acute  myelitis  and  encephalitis: 
there   appeared   spasmodic   movements   of  the  limbs,  and  the 
patient  became  wildly  delirious,  in  which  he  required  restraint 
to  prevent  him  from  doing  violence  to  those  attending  him.     On 
reopening  the  wound,  the  cord  was  found  swollen  and  protruding 
through  the  breach  which  had  been  made  in  the  vertebral  canal. 
The  patient  died  two  weeks  after  the  operation.      It  is  possible 
that  in  case  of  an  irreducible  luxation  lower  down  in  the  spinal 
column  an  operation  might  eventuate  more  favorably,  since  it 
would  permit  of  better  immobilization  than  is  possible  in  the 
region  of  the  atlas,  which  is  near  the  pivotal  point  of  the  move- 
ments of  the  head  upon  the  trunk. 


1150  LUXATION   OF    THE    CERVICAL    VERTEBR-E. 

Fracture  of  the  J^ertcbrae. — The  spinal  column  may  be  broken 
at  any  point,  yet  conforming  to  the  scope  of  this  work,  the  present 
chapter  will,  in  the  main,  be  briefly  devoted  to  fracture  of  the 
cervical  portion  of  the  column. 

The  vertebra  is  constituted  of  several  ])arts  which  function- 
ally differ:  viz.,  a  body,  seven  processes  and  two  lamellae.  The 
processes  aid  in  articulation,  or  serve  as  points  for  the  attachment 
of  ligaments  and  muscles;  and  the  lamellae  form  the  lateral  and 
posterior  walls  of  the  spinal  canal.  And  as  one  or  more  of  these 
constituent  ])arts  may  be  broken,  there  may  be  isolated  fracture 
of  the  body,  lamella,  articular,  transverse  or  spinous  process:  or 
two  or  more  of  these  parts  may  be  fractured  conjointl}". 

A^ertebral  fracture  may  arise  from  violence  indirectly  or 
directly  applied;  that  from  indirect  force  occurs  oftener  than  that 
from  direct. 

Molliere,  of  Lyons,  in  1887  wrote  on  spinal  fracture  caused  by 
indirect  violence;  and  in  his  researches  of  the  subject,  lie  made 
experiments  on  the  cadaver.  In  these  experiments  the  body 
was  fixed  in  a  sitting  posture,  and  then  violence  was  applied 
directly  downwards;  or  it  was  done  by  bending  the  body  back- 
wards or  forwards;  and  the  following  results  were  noted:  (1) 
Only  when  the  intervertebral  ligaments  remain  intact,  does 
crushing  of  the  vertebral  bodies  take  place.  (2)  Fracture  of 
the  vertebral  arches  only  takes  place  wdieii  the  bodies  remain 
intact.  (3)  When  one  produces  fracture  by  violently  flexing  the 
body,  then  the  fracture  will  be  found  in  the  vertebral  bodies; 
and  these  bodies  will  be  found  crushed  in  their  anterior  portion. 
(4)  Fracture  occurring  in  the  dorsal  region  is  accompanied  by 
costal  fracture,  or  sternal  fracture,  or  by  injury  of  the  costal 
cartilages.  If  the  flexion  be  confined  mainly  to  tlie  spinal 
column,  then  fracture  isoftenest  in  the  dorsal  region;  but  forcible 
flexion  of  the  trunk  is  more  apt  to  break  the  spine  in  the  lumbar 
region. 

Molliere  has  found  these  results  verified  in  surgical  practice. 
In  twelve  cases  of  spinal  fracture  caused  b}'  falling  on  the  feet, 
gluteal  or  sacral  region,  the  fracture  was  found  in  the  lower  part 
of  the  spine,  viz.,  the  portion  between  the  eleventh  dorsal  and  the 
third  lumbar  vertebra.  And  in  eight  cases  in  whicli  the  vio- 
lence was  from  falls  on  the  head,  tlie  site  of  fracture  was  in  the 
dorsal  region. 

An  epitomized  summary  of  Molliere's  researches  is  the  fol- 
lowing:   fracture  of  the   spine   occurs   indirectly    from    forced 


FRACTURE  OF  THE  VERTEBRA.  1151 

flexion  of  the  entire  trunk;  or  it  may  arise  from  forced  flexion  of 
the  normal  curves  of  the  spine;  and  in  the  latter  case  the 
violence  acts  on  both  ends  of  the  column.  And,  finally,  violent 
flexion  (.'an  break  the  spine  by  acting  on  one  end. 

Fracture  may  arise  from  violence  acting  directly  on  some 
part  of  the  median  line  of  the  back:  and  the  causal  agent  may, 
or  may  not,  penetrate  the  soft  parts.  Excepting  the  projectile, 
such  causal  agency  is  rare:  for  spinal  fracture  originates,  as  a 
rule,  from  indirect  agency:  for  example,  a  fall  on  the  feet  or  on 
the  buttocks  may  break  the  spine.  In  the  history  of  this  injury, 
there  are  many  cases  recorded  in  which  it  occurred  from  the 
subject  falling  head  downwards,  and  so  striking,  that  the  violence 
traversed  the  head,  neck  and  expended  its  force  on  the  spine.  A 
great  weight  falling  on  the  head,  inclined  neck,  or  shoulders,  has 
broken  the  spine,  and  such  force  usually  fractures  at  some  point 
in  the  upper  part  of  the  column.  Dupuytren  saw  a  case,  in 
which  a  slaughtered  ox  thrown  from  a  wagon  upon  the  shoulders 
of  a  man  caused  fracture  of  the  processes  of  the  fourth,  fifth  and 
sixth  vertebrae.  In  the  work  of  mining,  a  mass  of  over-hanging 
earth  or  rock  falling  on  the  shoulders  of  the  laborer  may  fracture 
the  spine:  a  few  cases  thus  occurring,  have  fallen  under  the 
observation  of  the  author.  In  athletic  sport,  in  the  act  of 
turning  about  a  bar,  a  young  man  fell  striking  on  his  head  and 
received  an  injury  in  wdiich  all  parts  below  the  neck  were 
paralyzed,  and  death  occurred  within  an  hour.  From  the 
simple  overthrowing  of  a  wagon,  the  spine  was  fractured  near 
the  middle,  in  a  case  seen  by  the  writer. 

An  accurate  diagnosis  between  vertebral  luxation  and  frac- 
ture is  difficult  to  be  made:  in  fact,  the  change  of  form  caused 
by  the  two,  and  the  morbid  conditions  resulting  from  them,  are 
often  so  similar  as  to  baffle  the  attempt  at  differentiation:  and 
the  difficulty  is  further  augmented  by  the  fact  that  in  many 
cases,  luxation  and  fracture  coexist.  The  body  of  the  vertebra, 
for  example,  may  be  fractured,  and  its  articular  processes  lux- 
ated, so  that  the  vertebra  is  displaced  backwards,  forwards  or 
laterally. 

Vertebral  fracture  is  usually  limited  to  one  vertebra;  excep- 
tionally, two  vertebrae  are  involved,  and  more  rarely   several 
vertebree  may  be  implicated  in  the  injury.     In  case  of  multiple  ■ 
fracture,  the  injury  is  usually  in  the  arches. 

If  vertebral  fracture  were  an  isolated  lesion,  it  would  not  be  a 
matter  of  great  import:  but  as  the   spinal   cord   is   commonly 


11. VJ 


I.rXATIOX    OF    THE    CKRVKAI.    VKUTKBK.i:. 


involved,  the  gravity  of  the  injury  is  dependent  on  tlje  location 
and  extent  of  the  lesion  of  the  cord.  If  the  cord  be  severed,  or 
so  crushed  that  the  part  beyond  is  rendered  functionless,  then 
the  effect  is  disastrous  to  the  part  of  tlie  body  which  receives  its 
supply  of  nerves  from  the  portion  of  the  cord  which  has  been 
cut  off. 

In  degree  or  extent,  the  fracture  may  vary  from  that  which 
is  simple  to  that  which  is  very  extensive:  viz.,  from  a  lesion 
indiscernible,  to  one  completely  crushing  the  vertebra:  and  from 
such  varving  conditions,  there  mav  be  founded  a  classification 
into  that  of  mere  seam  or  fissure,  compression,  and  a  still  higher 
degree,  in  which  the  vertebra  is  broken  into  two  or  more  pieces, 
and  these  may  or  may  not  be  displaced. 

The  fissure  may  be  nearly  or  quite  invisible;  or  it  may 
slightly  gape. 

In  the  second  form,  the  upper  and  lower  faces  of  the  body 
may  be  flattened  and  caused  to  approach  each  other:  and  along 
with  the  vertical  thickness  of  the  vertebral  body,  the  interverte- 


Figure  110.  Showins: complete  frac- 
ture of  the  vertebral  column.  (From 
Albert.) 


Figure  111.     Showing  fracture  of  a 
vertebra.     (From  Albert.) 


bral  disk  is  crushed  and  forced  from  its  place.  The  compressive 
force  may  merely  act  on  the  borders  of  the  articular  facets  of  the 
body;  or  the  violence  may  be  such  as  to  essentially  shorten  the 
vertical  thickness  of  the  body:  in  the  former  case,  the  cord  would 
escape  all  pressure;  but  in  the  latter,  the  canal  would  be 
encroached  on,  and  the  cord  subjected  to  some  pressure. 

Where  the  vertebral  body  has  been  broken  into  two  or  more 
pieces,  the  line  of  fracture  is  usually  oblique  or  horizontal;  and 


FRACTURE  OF  THE  VERTEBRAE.  1153 

this  is  usually  nearer  the  upper  surface  than  the  lower  one:  and 
then  the  smaller  upper  fragment  is  displaced  forwards;  and 
along  with  this,  the  superincumbent  column  above  is  carried 
forwards.  ,  In  such  displacement,  the  spinal  cord  is  pressed 
on  by  the  upjDer  displaced  portion  of  the  column;  and  if  the 
displacement  be  considerable,  the  cord  may  be  lacerated,  or 
even  entirely  severed.  Examples  of  vertebral  fracture  are  seen 
in  figures  110  and  111. 

The  proof  that  the  spine  has  been  broken  and  the  cord 
injured  is  furnished  by  the  impairment,  or  entire  loss  of  motion 
and  sensation  in  the  parts  deriving  their  nerves  from  the  portion 
of  the  cord  that  lies  below  the  fracture.  As  there  are  many 
varying  conditions  conceivable  in  the  injury,  so  there  may  be 
variety  in  the  functional  disturbance.  Charles  Bell  discovered 
and  proved  that  the  anterior  portion  of  the  cord  is  the  source  of 
motor  innervation,  and  that  the  posterior  portion  is  concerned  in 
sensation.  As  a  result  of  such  anatomical  disposition,  it  is 
evident  that  a  lesion  limited  to  the  anterior  or  posterior  portion 
of  the  cord  would  have  the  effect  of  destroying  or  disturbing- 
motion  or  sensation  in  the  parts  below  the  injury.  As  the  canal 
is  larger  in  the  upper  part  of  the  spinal  column  than  in  the 
lower  portion,  hence  functional  disturbance  would  ensue  from 
less  displacement  in  tlie  lower  than  in  the  upper  part  of  the 
spine. 

If  the  displacement  were  lateral,  or  in  the  direction  of  torsion, 
and  were  slight,  then  the  cord  might  escape  pressure,  and  the 
constriction  be  limited  to  the  nerves  which  escape  between  the 
displaced  vertebrae:  and  in  such  a  case,  the  nerves  which  are 
given  off  beneath  the  injury,  would  retain  unimpaired  function: 
and  the  remarkable  condition  would  be  present  that  a  zone  of 
the  body  would  present  impaired  movement  and  feeling,  wdiile 
above  and  below  such  zone,  there  would  be  integrity  of  move- 
ment and  sensation. 

Again,  the  displacement  may  be  slight  in  any  of  these  direc- 
tions, yet  from  lesion  of  blood-vessels,  a  clot  may  form  and 
produce  pressure  on  the  cord,  and  thence  conditions  can  arise 
which  are  similar  to  actual  severing  or  laceration  of  the  cord. 
But  as  the  clot  would  lessen  through  absorption,  the  paralytic 
condition  would  gradually  disappear.  And  it  is  probable  that 
in  those  cases  in  which  the  subsidence  of  the  paralysis  is  referred 
to  accommodation  of  the  cord  to  the  compressing  vertebra,  the 
actual  condition  has  been  one  of  compressing  clot  rather  than 
vertebral  displacement. 


1154  LUXATION    OF    THE    CEEVICAL    VERTEBRA. 

Observation  has  often  found  that  the  sphere  of  sensory 
impairment  is  less  than  that  of  loss  of  movement;  for  example, 
muscular  i>ovver  may  be  abolished  in  a  limb,  while  the  sensory 
endowment  is  not  com.jiletely  extinguished.  An  exj^ilanation  of 
this  may  be  found  in  structural  difi'erence  between  the  antei'ior 
and  posterior  roots:  the  posterior  roots  are  larger  than  the 
anterior  ones;  and  the  ])Osterior  roots  have  a  ganglionic  enlarge- 
ment, in  which  there  is  resident  some  sensory  endowment 
probably  independent  of  the  cord.  The  position  of  this  ganglion 
in  the  intervertebral  canal  may  protect  it  from  lesion  of  the 
adjacent  bony  structure.  These  anatomical  conditions  give  the 
posterior  or  sensory  trunks  an  advantage  over  the  anterior  ones. 
Another  circumstance  which  may  have  an  influence  is  that  in 
antero-posterior  displacement  (the  usual  one),  the  cord  is  more 
infracted  in  its  anterior  than  in  its  posterior  section;  and  thence 
may  arise  a  greater  disturbance  of  motor  than  of  sensory 
function. 

The  area  of  paralysis  may  be  irregular  below  the  site  of  the 
injured  cord:  for  example,  it  maybe  hemiplegic;  and  again,  it 
ma}'  be  complete  on  one  side  and  incomplete  on  the  other.  A 
reason  which  may  be  suggested  for  this  inequality  is  that  in  the 
injury,  some  of  the  nervous  fibrillse  of  the  cord  may  remain 
undivided,  or  but  slightly  compressed:  and  hence  the  continuity 
of  innervation  is  not  wholly  interrupted. 

The  remarkable  condition  in  which  nerve  function  is  not 
wholly  annulled  in  parts  below  the  spinal  injury  may  be 
explained  in  yet  another  way,  which,  though  a  conjecture,  seems 
to  the  writer  not  improbable.  If  one  studies  the  symiDathetic 
nervous  cord,  there  are  found  to  be  numerous  intercommunicating 
trunks  which  connect  the  sympathetic  to  the  spinal  cord.  And 
through  intercommunicating  bands,  in  the  case  of  rupture  of  the 
cord,  there  remains  an  indirect  channel  of  connection  and  com- 
munication between  the  two  portions  of  the  spinal  marrow.  In 
such  condition,  the  sympathetic  cord  may  serve  as  a  bridge  across 
the  breach.  The  plexus  which  is  formed  by  converging  trunks 
from  separate  points  of  the  cord,  and  which  distributes  diverging 
branches,  becomes  a  medium  for  the  restoration  of  innervation 
through  indirect  routes:  and  through  such  by-path  the  nervous 
influence  may  jflnd  transit  for  itself.  And,  again,  at  the  periph- 
eral ending  of  nerves  there  may  be  intercommunication  between 
filaments  which  arise  from  separate  sections  of  the  cord.  And, 
finally,   sensation   may   survive  in  the  surface    through   some 


FRACTURE  OP  THE  VERTEBRA.  1155 

special  ganglion-like  formation  at  the  end  of  the  peripheral 
filament. 

As  the  limits  of  this  work  exclude  a  special  consideration  of 
the  parts  of  the  body  below  the  neck,  the  remainder  of  this  article 
will  be  confined  to  a  short  consideration  of  spinal  fracture  occur- 
ring in  the  cervical  region. 

Fracture  in  the  upper  part  of  the  vertebral  column  occurs 
most  frequently  between  the  fifth  cervical  and  first  dorsal  verte- 
brse,  yet  it  may  take  place  at  any  other  point:  and  the  most 
common  causal  agency  is  from  forcible  anterior  flexion.  The 
spinal  marrow  rarely  escapes  injury:  yet  the  large  caliber  of 
the  spinal  canal,  especially  as  one  approaches  the  occiput,  may 
screen  the  cord  from  injury,  provided  the  displacement  is  slight 
or  absent.  In  case  the  fracture  originate  from  super-flexion,  if 
there  be  displacement,  this  will  consist  of  the  upper  segment  of 
the  column  being  carried  forwards,  beyond  the  one  below;  and 
thence  must  arise  compression,  laceration,  or  complete  division  of 
the  spinal  marrow. 

The  consequence  of  such  injury  will  be  different  according  to 
the  amount  of  lesion  of  the  cord:  if  the  division  of  the  latter  be 
incomplete,  the  palsy  arising  will  also  be  incomplete.  The 
brachial  plexus  is  formed  by  the  commingling  of  the  four  lower 
cervical  and  first  dorsal  nerves:  and  should  the  origin  of  one  or 
more  of  these  nerves  escape  injury,  then  the  tract  to  which  the 
same  is  distributed,  will  escape  paralysis.  And  according  to 
Thorburn,  who  has  studied  this  subject,  such  palsy  may  be  in  the 
scapular  muscles  of  the  upper  arm,  lower  armor  hand,  according 
as  the  injury  is  limited  to  the  fourth,  fifth.,  sixth,  seventh,  eighth 
or  ninth  nerve.  And,  hence,  as  examples  of  isolated  injury  of  the 
motor  and  sensory  endowment  of  the  upper  extremity,  the  follow- 
ing may  be  mentioned.  Rupture  of  the  cord  between  the  fourth 
and  sixth  vertebrse  will  affect  the  power  of  elevation,  flexion, 
abduction  and  supination  of  the  upper  arm  and  elbow;  rupture 
above  and  near  the  sixth  vertebra  will  interfere  with  the  exten- 
sion of  the  elbow:  that  is,  it  will  palsy  the  triceps  extensor  cubiti. 
Rupture  at  the  seventh  vertebra  will  paralyze  the  extensors  of  the 
wrist;  and  if  the  injury  be  a  little  lower,  the  flexion  of  the  wrist 
will  be  lost. 

In  consequence  of  the  cilio-spinal  center  or  nucleus  of  the 
innervation  of  the  iris  being  located  in  the  lower  part  of  the 
cervical  portion  of  the  cord,  injury  of  that  part  may  disturb  the 
normal  movements  of  the  pupil. 


1150  hUXATKix  OK  THE  CERVICAL  V Kiri' i;i!i;.i:. 

By  far  the  most  iiiijDortant  nerve  wliicli  origiiuitcs  I'roin  tlic 
cervical  section  of  the  spinal  cord  is  the  ]»hrenic:  its  origin  is 
from  the  fourth  and  liftli  cervical  nerves;  and  this  corresponds 
approximately  to  the  fourth  cervical  vertebra.  A  fracture  below 
this  point  permits  the  continuance  of  life  for  at  least  a  few  days; 
but  if  the  cord  be  broken  above  this,  death  is  instantaneous. 
Hence  the  movement  of  thediaphragm,in  case  of  spinal  fracture 
in  the  cervical  region,  if  unimpaired,  denotes  fracture  below  the 
fifth  vertebra:  if  incomplete,  it  signifies  probably  fracture  through 
the  fifth  vertebra.  Many  years  ago,  Marshal  Hall  visited  a  hospi- 
tal to  which  the  writer  was  attached;  the  learned  neurologist 
was  shown  a  patient  who  had  recently  fractured  his  spine  in  the 
cervical  region:  the  physician,  as  the  first  step  in  the  examination, 
passed  his  hand  beneath  the  covering  of  the  patient,  and  finding 
that  there  was  free  movement  of  the  diaphragm,  he  remarked 
that  the  fracture  was  below  the  origin  of  the  phrenic  nerve;  and 
the  diagnostic  acumen  displayed,  great  for  that  period,  awakened 
admiration  among  the  young  medical  men  who  were  present. 

If  the  lesion  should  be  in  the  thoracic  region  of  the  spine, 
besides  the  phrenic  nerve,  some  of  the  intercostal  nerves  might 
be  spared  :  and  then,  in  breathing,  besides  the  movement  of  the 
diaphragm  by  which  the  inspiratory  act  is  normally  accom- 
plished, the  movement  of  expiration  might  be  aided  by  the 
intercostal  muscles. 

If  the  injury  be  so  high  that  only  the  phrenic  nerve  escapes, 
then  the  normal  inspiratory  movement  will  be  rhythmically 
made:  the  diaphragm  descending,  the  lungs  will  be  filled  with 
air:  but  in  this,  the  work  of  respiration  is  but  half  done;  an 
equally  important  part  remains  to  be  accomplished,  viz.,  the 
expulsion  of  the  air:  this  is  but  imperfectly  eftected  by  the 
resilient  movement  of  the  compressed  abdominal  viscera  forcing 
the  diaphragm  upwards;  also  by  the  elastic  force  inherent  in  the 
pulmonary  structure,  due  to  the  muscular  tissue  which  Moles- 
chott  finds  that  the  lungs  possess;  and,  lastly,  there  is  some 
expulsive  force  exerted  by  the  recoil  of  the  u[)lifted  walls  of  the 
chest.  By  these  united  forces,  which  are  all  of  a  passive  charac- 
ter, the  inspired  air  is  only  incompletely  expelled.  And,  further, 
those  acts  of  the  body  which  require  expiratory  effort,  cannot  be 
performed.  For  example,  the  subject  of  such  injury  cannot 
cough;  an  attempt  to  do  so  is  of  a  spasmodic  character,  similar 
to  sneezing. 

In  case  of  fracture  below  the  origin  of  the  phrenic  nerve, 


FRACTURE  OF  THE  VERTEBRAE.  1157 

besides  the  respiratory  disturbance  mentioned,  there  arise  other 
serious  troubles,  which  require  description.  In  a  few  cases 
observed,  the  temperature  was  lowered;  sometimes  much  below 
the  normal  standard;  but,  as  a  rule,  the  temperature  rose,  and 
has  been  known  to  reach  one  hundred  and  nine  degrees  Fahren- 
heit; and  even  an  elevation  of  heat  to  one  hundred  and  twenty-two 
degrees  was  seen  by  Teale;  but  probabh^  there  was  an  error  in 
this  observation,  or  its  record. 

The  pulse  may  not  vary  much  from  normal  in  the  early  stage 
of  the  injirry;  but  in  the  more  advanced  stage  the  pulse  becomes 
accelerated. 

The  secretion  of  urine  maybe  normal  for  a  time:  yet  fre- 
quently, it  is  lessened  in  amount.  Sometimes,  from  passive  con- 
gestion of  the  coats  of  the  bladder,  blood  escapes  from  the  turgid 
vessels,  and  hsematuria  is  present.  In  composition  the  urine 
remains  normal  for  a  period;  later,  it  becomes  alkaline. 

As  the  bladder  is  palsied,  it  retains  the  urine  and  soon 
becomes  excessively  distended;  and  as  a  result,  there  is  an 
increased  excretion  of  mucus,  that  alters  the  constitution  of  the 
urine,  which,  in  turn,  reacts  ill  on  the  vesical  w^all.  And  these 
morbid  agencies  are  soon  reenforced  by  the  appearance  on  the 
scene  of  rapidly  multiplying  bacteria.  The  power  of  voiding  the 
bladder  is  entirely  lost;  and  the  urine  continues  to  augment  until 
the  neck  is  forcibly  dilated,  and  then  the  urine,  from  time  to 
time,  trickles  away.  And  should  such  escape  not  occur,  then  the 
bladder  slowly  expands  and  rising  into  the  abdominal  cavit}', 
resembles  an  immense  cyst-like  tumor.  Though  the  timely  use 
of  the  catheter  may  prevent  such  accumulation,  still  the  urine 
usually  becomes  laden  with  mucus  charged  with  ammonia,  and 
is  otherwise  abnormal  in  composition;  and  then  the  walls  of 
the  bladder  become  the  seat  of  changes  similar  to  those  of  chronic 
cystitis.  Inasmuch  as  the  trunk  is  paralyzed,  the  patient  is  quite 
insensible  to  these  conditions  of  the  bladder,  which  in  the  non- 
palsied  subject  would  be  the  source  of  indescribable  torment. 

These  conditions  of  the  bladder  cannot  continue  without 
finally  implicating. the  kidneys:  the  latter  are  impaired  in  func- 
tion, and  become  trammeled  in  their  work  of  depuration.  The 
blood  being  imperfectly  oxygenated  and  depurated  is  unable  to 
maintain  the  tissues  at  their  normal  standard  of  vitality:  hence 
the  readiness  with  which  parts  slough  when  they  are  subjected 
to  pressure.  In  the  normal  condition  of  the  blood,  the  pressure 
though  prolonged  on  the  gluteal  and  dorsal  structures,  is  toler- 


1158  LUXATION    OF    THE    CKRVICAL    VERTEBK.E. 

ated  ;  for  example,  in  the  phthisical  patient  such  pressure  will  be 
endured  for  an  indefinitely  long  time;  while  in  the  subject  of 
fracture  existing  high  in  the  spine,  immense  sloughing  will  soon 
take  place.  This  tendency  to  sloughing  from  slight  cause  may 
find  some  explanation  in  the  loss  of  sensory  innervation  of  the 
parts:  for,  as  is  known,  the  sensory  nerves  have  some  agency  in 
the  nutrition  of  the  tissues:  verification  of  this  is  obtained  in 
vivisective  work  in  animals,  or,  its  counterpart,  in  surgical  work 
on  man.  In  recent  periods,  when  the  surgeon's  knife  has  invaded 
regions  once  considered  impenetrable,  the  cranial  cavity  has  been 
opened  and  the  trifacial  nerve  has  been  severed  for  relief  of  facial 
neuralgia:  and  though  the  pain  was  thus  extinguished,  vision 
was  lost  through  sloughing  of  the  cornea. 

An  occasional  accompaniment  of  spinal  fracture  is  priapism; 
the  patient  has  no  consciousness  of  the  condition:  this  erectile 
state  is  by  no  means  a  constant  one:  in  nearly  all  the  cases  of 
spinal  fracture  seen  by  the  writer,  it  was  absent;  and  when  pres- 
ent, the  erection  was  imperfect;  and  it  was  rather  one  of  passive 
congestion  of  the  part,  than  of  active  priapism.  The  erectile 
condition  rarely  appears  until  the  bladder  has  become  distended 
with  urine;  or  until  the  viscus  has  been  irritated  by  the  intro- 
duction of  a  catheter. 

Through  the  weakened  condition  of  the  abdominal  wall  the 
normal  compression  is  withheld  from  the  bowels;  and  as  a  result 
of  this,  they  become  tympanitic.  Tliis  tympanites  interferes 
with  the  movement  of  the  diaphragm,  and  disturbs  the  inspira- 
tory movement  of  respiration;  but,  on  the  other  hand,  it  i)romotes 
the  expulsion  from  the  lungs  of  the  inspired  air. 

The  sphincter  muscles  of  the  rectum  are  wholly  palsied;  and 
as  result,  there  is  no  restraining  action  exercised  by  the  bowel 
on  its  content.  The  anomalous  state  of  the  bowel  presents  itself, 
in  which  constipation  and  diarrhoea  succeed  each  other,  alter- 
nately. The  fsecal  content  collects  in  the  colon  until  the  mass  is 
so  great  that  it  descends  by  its  weight;  and  when  the  hardened 
portion  has  passed  out,  the  succeeding  li(|uid  material  continues 
to  escape  for  some  time,  similarly  to  what  occurs  in  diarrhoea. 
The  bowels  unaided  will  move  once  or  twice  a  week.  And 
though  sensation  is  absent  in  the  parts,  yet  the  patient  is  con- 
scious of  the  accumulation  of  fseces  through  flushed  face  and 
headache. 

As  stated,  cervical  fracture  above  the  fourth  vertebra  is 
quickly  fatal,  but  in  the  region  of  the  fifth,  sixth,  seventh  or 


FRACTURE    OF    THE    VERTEBRAE.  1159 

eighth  vertebra,  death  is  not  so  immediate  :  but  in  such  patients 
life  is  rarely  prolonged  beyond  the  fourth  or  fifth  day.  Hence 
vertebral  fracture  in  the  cervical  region  of  the  spine  is  an  exceed- 
ii^gly  gi'ave  injury,  in  fact,  one  of  the  most  perilous  that  can 
befall  the  human  body. 

Though  the  injury  be  grave,  its  gravity  may  be  increased  if 
the  patient  be  incautiously  lifted  or  carelessly  carried:  fur 
through  such  negligence,  the  incompletely  ruptured  cord  may 
be  entirely  severed.  Hence  the  subject  of  this  accident  should 
be  lifted  and  placed  on  a  stretcher  or  carrying  appliance, 
which  should  be  solid  or  unyielding.  A  broad  plank  seven  feet 
long  laid  on  two  cross-bars  will  answer  for  such  carriage.  To 
place  the  patient  on  this,  four  assistants  are  necessary:  viz.,  one  to 
lift  the  lower  extremities,  two  the  trunk,  and  one  to  support  the 
head.  By  such  assistance,  the  patient  is  so  lifted,  that  the  spinal 
column  is  safely  cared  for,  and  no  sliding  nor  displacement  of  the 
broken  part  can  take  place.  If  the  plank  mentioned  be  used  for 
transporting  the  patient,  the  head  should  be  somewhat  supported 
by  a  pillow  laid  beneath  it;  and  this  support  can  be  formed  of  the 
patient's  coat,  properly  folded.  The  patient  should  be  carried 
feet  foremost:  in  the  same  manner  as  the  wounded  soldier  is 
borne  from  the  field.  And  thus  carried,  the  subject  of  spinal 
fracture  can  have  additional  care  from  an  assistant,  who,  follow- 
ing, places  his  hands  on  each  side  of  the  patient's  head,  and  pro- 
tects it  from  jostling.  With  these  precautions,  the  patient  is  to  be 
borne  to  the  room  where  he  is  to  remain  during  treatment.  The 
next  thing  demanding  careful  attention  is  to  prepare  a  proper 
bed  for  the  patient.  For  this  purpose,  the  bed  used  for  the  treat- 
ment of  the  fractured  femur  may  be  used:  viz.,  the  so-called 
fracture  bed ;  but  in  place  of  the  hair  or  straw  mattress,  the  bed 
must  have  an  air  or  water  sack,  upon  which  the  patient  will  lie. 
This  sack  is  made  of  India-rubber  cloth,  and  is  provided  with  an 
opening  at  one  of  its  corners,  through  which  air  or  water  can  be 
introduced,  and  retained  there  by  a  stop-screw.  In  case  the 
injured  patient  can  yet  move  himself,  the  air-couch  is  preferable 
to  that  of  water;  since  in  moving  laterally  on  the  latter,  the  fluc- 
tuating water  may  roll  the  patient  out  of  bed.  The  writer  knew 
of  such  an  accident,  in  which  the  subject  of  spinal  lesion  was  thus 
cast  from  the  bed,  and  injuries  received  that  finally  ended  life. 
It  should  be  remarked  that  such  ejection  from  the  bed  could  more 
readily  occur  from  a  narrow,  than  from  a  wide  one.  And  in  the 
construction  of  the  bed,  provision  should  be  made  for  lowering  a 


1160  LUXATION    OK    TlIK    CKRVICAL    VKKTKBRyE. 

portion  of  it,  so  that  a  vessel  for  receiving  excrement  may  be 
used  as  occasion  requires.  The  bed  may  liave  other  appliance 
or  attachment,  according  to  the  i)lan  of  treatment  which  is 
pursued. 

The  bed  being  arranged,  tiie  patient  must  be  removed  from 
the  stretcher  to  the  bed  :  and  the  shifting  from  the  carrying 
stretcher  must  be  carefully  done,  the  same  assistants  are  needed, 
and  the  same  precautions  must  be  observed,  as  were  used  in  plac- 
ing the  patient  on  tlie  stretcher;  one  aid  should  lift  and  maintain 
the  head  at  rest;  two  should  support  the  trunk,  and  one  should 
carry  the  lower  extremities.  The  patient,  being  lifted  by  these 
assistants  from  the  stretcher,  is  to  be  carefully  laid  on  the  per- 
manent bed  that  has  been  made  ready  for  him. 

The  prognosis  of  spinal  fracture  in  the  cervical  region  is  inaus- 
picious in  the  extreme:  in  fact,  is  fatal  if  the  cord  has  been 
wholly  divided;  j^et,  as  the  extent  of  the  wound  is  often  indeter- 
minable, no  effort  looking  towards  reparation  of  the  injur\^ 
should  be  neglected.  The  treatment  may  be  classified  under  three 
headings,  that  of  simple  rest,  mechanical,  and  operative. 

The  method  of  rest  is  to  reduce  the  broken  parts  to  normal 
position,  and  then  to  maintain  the  body  as  nearly  motionless,  as 
possible. 

Should  the  lesion  of  the  cord  be  a  slight  one,  and  the  func- 
tional impairment  arise  from  clotted  blood  which  has  been 
effused,  then  it  is  probable  that  absorption  may  occur,  and  the 
slight  breach  in  the  cord  be  repaired.  Such  re})air  will  be  tedi- 
ous, since  tho  disposition  of  the  rhacliidian  vessels  is  far  from 
favorable  for  restitution  to  integrity.  And  the  dorsal  posi- 
tion of  the  patient,  disposing  as  it  does,  to  hypostatic  plethora  of 
the  injured  part,  is  an  agency  which  opposes  recovery  :  in  fact, 
renders  complete  repair  scarcely  possible. 

This  stasis  of  blood  about  the  injury  from  dorsal  recumbence 
has,  probabl}'',  not  been  taken  sufficiently  into  account;  and  the 
query  arises,  Would  it  be  possible  to  avoid  this  by  placing  the 
patient  in  a  prone,  or  nearly  prone,  position?  There  would  cer- 
tainly be  many  difficulties  which  would  antagonize  an  attempt  to 
pursue  treatment  in  such  position,  yet  the  advantages  whicli  it 
would  give  in  preventing  congestion  commend  a  trial  of  it.  That 
such  position  can  be  tolerated  is  shown  by  the  observation  of 
Blandin,  who  announced,  as  early  as  1S45,  that  patients  suffering 
from  spinal  disease  can  be  treated  in  the  prone  posture,  and 
though  the  position  is  uncomfortable  at  first,  yet  the  patient  soon 
learns  to  tolerate  it. 


FRACTURE  OF  THE  VERTEBRA.  ll(jl 

One  of  the  grave  complications  of  spinal  fracture  is  the  super- 
vention of  sloughing  of  the  parts  subjected  to  pressure;  atten- 
tion should  be  given  to  this,  and  an  attempt  made  to  avoid  it 
as  far  as  is  possible.  For  this  purpose,  continuous  pressure  of 
a  part  should  be  avoided  by  supports  which  will  distribute  the 
pressure,  or  take  it  from  prominences  which  rest  on  the  mattress. 
Besides  this,  the  parts  acted  on  may  be  given  some  resistance  bv 
washing  them  with  alcohol,  or  with  a  weak  solution  of  corrosive 
sublimate:  viz.,  one  part  in  one  thousand.  The  part  may  be  hard- 
ened by  occasionally  sponging  it  with  Tinctura  Gallse;  and  it  may 
be  given  a  protective  coating  with  the  compound  tincture  of 
benzoin. 

The  evacuation  of  the  patient's  bladder  is  a  matter  which 
demands  unremitting  attention:  the  urine  should  be  removed 
with  a  soft  aseptic  catheter  three  times  in  twenty-four  hours. 
The  removal  of  the  urine  in  this  way  will  prevent  its  decomposi- 
tion, which  otherwise  would  ensue.  Despite  these  precautions, 
should  the  urine  undergo  alkaline  putrefaction,  then,  beside  the 
evacuation  of  the  urine,  there  is  the  need  of  using  means  to  purify 
the  vesical  cavity,  and  for  this  purpose  a  solution  of  boracic  acid 
may  be  injected.  For  this  purpose,  one  may  also  use  simple 
boiled  water,  which  has  been  slightly  acidified  with  nitric  or 
hydrochloric  acid. 

The  bowels  should  be  evacuated  once  in  forty-eight  hours; 
and  this  is  best  done  by  means  of  a  stimijlating  enema;  and  for 
this  purpose,  the  following  mixture  may  be  employed : — 

^.      Ex.  Sennse  Fl. 

Glycerin! .aa  gss 

OL  Tiglii gtti 

Misce. 

And  should  this  finally  fail  to  act,  the  croton  oil  should  be 
increased  to  two  or  three  drops,  in  each  injection. 

The  attentions  to  the  skin,  bladder  and  bowels  which  have 
been  described,  are  applicable  to,  and  demanded  in,  all  cases, 
whether  the  patient  be  treated  by  simple  rest,  mechanically,  or 
operatively. 

In  1844,  Hecker,  from  a  study  of  the  means  then  in  use  in 
the  treatment  of  fractured  spine,  and  the  unsatisfactory  results 
obtained,  urged  that  some  other  method  should  be  resorted  to; 
and  thus  avoid  the  slow  and  agonizing  death,  in  which  such 
accident  usually  terminates.  Hecker  has  some  hope  of  a  better 
74 


11G2  LUXATION    OF    THE    CERVICAL    VERTEBRA. 

ending  by  the  use  of  extension,  which  had  been  advised  and 
practiced  by  Crawfoot.  In  the  treatment  of  a  few  cases,  Craw- 
foot  obtaineil  excellent  results  by  fastening  the  patient's  trunlc  to 
a  bed,  and  then  making  traction  on  the  feet.  Hecker  thinks 
such  extension  should  be  tried  in  all  cases  of  spinal  fracture:  and 
this  failing,  he  would  trephine  tlie  spinal  column  at  the  site  of 
injury. 

The  object  of  extension  being  to  restore  the  broken  column 
to  normal  line,  the  traction  should  be  continued  for  some  time 
in  order  to  be  effective:  at  least  for  two  months,  which  is  the 
average  time  required  for  the  union  of  a  broken  bone.  The 
work  may  be  done  on  the  water  or  air  bed  by  means  of  weights 
and  pulleys,  with  attachment  at  the  feet.  Before  tiiese  retentive 
weights  are  applied,  an  attempt  should  be  made  to  reduce  the 
broken  vertebra?  to  normal  situation:  and  this  can  be  accom- 
plished b}^  firmly  holding  and  fixing  the  head,  wliile  traction  is 
being  made  on  the  feet;  or  the  traction  might  be  made  on  both 
the  head  and  the  feet;  and  while  such  extension  is  being  made, 
the  surgeon  may  cooperate  and  control  the  adjustment  of  the 
displaced  parts  by  pressing  against  the  portion  of  the  spine 
which  projects  and  deviates  from  the  normal  line.  This  control- 
ling work  of  reduction  must  not  be  overdone,  lest  the  lesion  of 
the  cord  may  be  increased. 

Inasmuch  as  the  paralyzed  parts  of  the  body  will  not  tolerate 
compression  without  ploughing,  there  is  a  serious  objection 
to  attaching  the  appliance  of  traction  to  the  palsied  inferior 
extremities;  therefore,  it  is  better  to  do  the  work  otherwise.  For 
this  purpose  let  the  bed  be  converted  into  an  inclined  plane, 
sloping  toward  the  feet;  and  then  include  the  head  in  a 
fenestrated,  halter-like  helmet,  which  can  be  fastened  to  the  head 
of  the  bed:  or  a  cord  attached  to  the  head-gear  can  be  passed 
over  a  pulley,  and  by  means  of  weights,  any  degree  of  traction 
needed  can  be  made.  The  head-gear  here  used  is  similar  to  that 
employed  by  the  orthopedist  for  suspension  of  the  body  in  cases 
of  spinal  curvature. 

When  the  patient  is  treated  in  this  manner,  the  body,  tending 
to  slide  down  the  inclined  bed,  acts  as  an  extending  force,  and 
maintains  the  broken  parts  in  corrected  position. 

Another  plan  of  treatment  which  has  its  advocates  is  to 
suspend  the  patient  in  the  suspending  appliance  of  the  orthope- 
dist, and  having  reduced  the  broken  spine  to  integrity  of  outline 
and  form,  to  enclose  the  upper  part  of  the  trunk  in  a  gypsum 


FRACTURE  OF  THE  VERTEBRiE.  1163 

casement.  In  the  application  of  the  gypsum,  care  must  be  used 
npj:  to  compress  the  thorax:  for  it  must  be  recollected,  that  in  the 
high  spinal  fracture  here  under  consideration,  the  ribs  do  not 
move  actively,  since  the  breathing  is  done  by  the  diaphragm.  A 
tightly-fitting  gypsum  casement  would  interfere  with  the  action 
of  the  diaphragm,  and  render  the  breathing  more  laborious:  in 
fact,  the  patient's  life  might  be  destroyed.  Even  in  the  healthy 
subject,  it  is  perilous  to  encase  the  thorax  tightly  in  plaster  of 
Paris. 

This  was  illustrated,  a  few  years  ago,  in  the  application  of 
gypsum  to  the  trunk  of  a  man  for  the  purpose  of  making  his 
bust.  The  man's  trunk  was  incased  in  the  plaster  and  he  was 
left  alone,  for  some  time.  The  material  hardened,  and  the  case 
became  smaller,  so  that  the  man  could  hardly  breathe  when 
found,  and  with  difficulty  he  was  rescued  from  his  perilous  position. 

The  subject  of  spinal  fracture  is  so  rarely  cured  by  the 
methods  which  have  been  described,  that  from  time  to  time,  in 
the  history  of  the  injury,  surgeons  have  sought  to  get  relief 
through  operative  means:  viz.,  to  open  down  on  the  fractured 
spine,  and  thus  uplift  or  remove  the  portion  of  the  vertebra 
which  compressed  the  cord.  The  early  essays  in  this  section  of 
surgery,  as  a  rule,  resulted  so  unsatisfactorily,  that  such  opera- 
tions were  rarely  done;  and,  in  fact,  some  recent  authorities,  dis- 
couraged by  the  frequent  failure  to  cure  by  operating,  do  not 
advise  it;  for  example,  Burrell,  of  Boston,  in  1887,  discarding 
knife  and  trephine,  advises  to  suspend  the  patient,  and  having 
thus  rectified  the  displacement,  he  applies  a  gypsum  cast.  But 
in  recent  years,  better  results  have  been  obtained,  so  that 
rachitomy,  as  the  operation  may  be  denominated,  may  now  be 
said  to  have  an  accredited  position  among  surgical  operations;, 
and  this  is  justified  by  the  statistics  of  White,  who  finds  the- 
results  of  twenty-seven  operations  to  be  the  following:  six  entire 
recoveries,  six  incomplete  recoveries,  eleven  cases  in  which  there- 
was  no  benefit  from  the  operation,  and  fourteen  patients  who 
died  soon  after  the  operation:  the  result  being  a  death-rate  of 
thirty-eight  per  cent.  Though  the  number  of  observations  was 
too  small  to  generalize  from,  yet  the  facts  speak  in  favor  of 
interference. 

Among  the  early  operators  for  spinal  fracture  was  Potter,,  an 
American  surgeon,  who,  in  1863,  in  a  case  of  fracture  in  the  cer- 
vical region,  in  which  there  was  palsy  of  the  upper  and  lower 
extremities,  trephined  and  removed  the  arch  of  the  fifth  vertebra. 


llG-1  LUXATION  OF  THE  CKUVJCAL  VEKTi;i;i;.i:. 

and  the  spinous  process  of  the  sixth  one.  The  result  was  that 
the  wound  healed  readily,  and  there  was  a  sliglit  return  of  motor 
function  on  the  left  side,  especially  in  the  left  hand.  The  patient 
remaining  in  a  helpless  condition,  three  years  afterwards,  Potter 
operated  again,  and  claims  to  have  removed  the  fourth,  fifth  and 
sixth  vertebra}.  This  operation  afforded  no  relief,  and  it  was 
discovered  by  it,  that  the  ruptured  cord  had  not  healed.  lie 
0])erated  in  other  cases  of  similar  character,  and  obtained  in  one 
case,  a  complete  recovery.  He  states  that  after  the  operation, 
the  patients  emaciated  for  some  time,  and  remained  thus  tem- 
porarily; and  later  they  regained  and  retained  their  flesh.  The 
report  of  Potter's  operative  work  is  less  extended  than  could 
be  wished;  yet  enough  was  learned  to  justify  further  effort  of  the 
kind  in  a  class  of  patients,  who,  otherwise,  would  remain  hope- 
lessly palsied. 

In  the  case  of  fracture  due  to  a  blow  or  body  striking  the  spine, 
that  is,  to  direct  violence,  the  indications  for  operating  are  more 
positive  and  imperative,  since  the  causal  agency,  acting  from 
behind  on  one  or  more  vertebne,  would  probably  be  limited 
to  the  spinous  processes,  or  vertebral  arches.  In  injury  thus 
arising,  the  patient  being  placed  in  a  prone  position,  and  a 
longitudinal  incision  being  made  in  the  median  line,  the  spinous 
processes  can  be  reached,  and,  by  means  of  a  chisel  or  blunt 
dissector,  separated  from  their  periosteal  and  ligamentous 
investment;  and  if  the  injury  be  found  to  be  limited  to  one  or 
more  spines  which  are  broken  and  pressed  into  the  spinal  canal, 
then  the  operation  could  be  completed  b}'^  the  simple  removal  of 
the  loose  spine  or  spines.  If  the  fracture  be  more  extensive,  and 
involve  the  laminated  wall  of  the  canal  at  its  side  or  pedicle, 
then  a  detached  fragment  may  be  removed,  and  the  remaining 
part  of  the  wall  be  uplifted  and  restored  to  proper  site.  A 
careful  search  for  spiculse  should  be  made,  and,  if  found,  they 
must  be  removed.  This  work  having  been  done  aseptically,  the 
wound  may  be  closed  by  sutures,  and  dressed  with  lint  saturated 
with  a  twenty-five  per  cent  solution  of  alcohol.  In  injuries  of  the 
limited  kind  mentioned,  healing  of  the  wound  will  be  obtained 
in  a  few  weeks;  but  if  the  cord  be  injured  to  any  extent,  the 
patient  may  require  a  long  time  to  recover  from  the  motor  and 
sensory  disturbance  which  has  arisen  from  the  injury 

In  case  the  fracture  has  arisen  from  violent  torsion,  flexion  or 
extension  of  the  spinal  column,  then  the  injury  is  commonly 
more  extensive  than  that  which  has  just  been  considered;  since, 


FRACTURE  OF  THE  VERTEBRA.  1165 

besides  fracture  of  the  arch,  the  vertebral  body  may  be  broken; 
and,  with  the  fracture,  there  may  be  displacement.  In  such 
injury  two  or  more  vertebrae  may  be  implicated  in  the  fracture. 

The  treatment,  here,  should  commence  with  an  attempt  to 
restore  the  broken  column  to  proper  position  by  traction  and 
counter-traction :  in  fact,  the  work  to  be  done  is  analogous  to  that 
resorted  to,  to  restore  to  position  the  fractured  parts  of  a  broken 
bone  of  the  arm  or  leg ;  while  traction  is  being  done,  the  hands 
of  the  surgeon  should  be  applied  to  the  injured  part,  and 
coaptation  accomplished  as  far  as  possible.  When  this  work  has 
been  done,  if  the  cord  has  merely  been  compressed,  it  is  probable 
that  the  motor  and  sensory  disturbance  will  disappear.  Should 
such  fortunate  result  follow  the  work  of  traction  and  coaptation, 
the  remaining  treatment  will  consist  in  retaining  the  patient  in 
recumbence  for  a  number  of  weeks;  and,  in  this,  the  prone  is 
better  than  the  supine  position. 

The  attempt  to  restore  the  broken  vertebral  column  to  normal 
form,  will,  owing  to  the  conditions  pres'ent,  rarely  bring  relief; 
yet  to  passively  fold  the  hands,  and  to  commit  the  case  to  nature 
already  overburdened,  is  most  unsatisfactory.  To  make  an  effort, 
even  though  nothing  is  hoped  from  the  attempt,  is  more  satisfac- 
tory to  the  victim  than  idle  abandonment  of  him.  And  there  is 
the  chance  that  by  the  exposure  of  the  spinal  column  and  exsec- 
tion  of  a  portion  of  one  or  more  vertebrge,  the  work  of  traction  and 
counter-traction  may  effect  restoration  to  normal  anatomical  form. 

In  the  operation  here  proposed,  the  patient  should  lie  prone, 
and  provision  be  made  for  traction  and  counter-traction,  when  the 
excision  has  been  done.  A  longitudinal  cut  should  be  made  to 
the  spinous  processes  corresponding  to  the  site  of  injury;  the  soft 
parts  are  then  to  be  reflected  laterally;  and  in  this  separation  of 
these  parts  from  the  bones,  the  periosteum,  as  far  as  possible, 
should  also  be  included  and  reflected  laterally.  By  such  prepara- 
tory incision,  which  should  be  ample  in  dimensions,  the  field  is 
opened  in  which  the  broken  vertebrae  can  be  seen,  and  any  work 
done  on  the  latter  which  the  cliaracter  of  their  injury  may 
indicate.  For  example,  a  lateral  opening  may  be  made  with  a 
trephine  at  one  or  more  points,  and  the  cord  examined.  And 
then  with  cutting  forceps,  enough  of  the  wall  may  be  removed  to 
liberate  the  cord  from  all  pressure.  And  should  there  be  dis- 
placement of  one  or  more  of  the  vertebral  bodies,  it  may  be 
possible,  by  extending  and  counter-extending,  to  restore  the  dis- 
placed parts  to  normal  position.     The  excision,  as  reported  done 


11G()  LUXATION    OF    THK    CI-^KVICAL    VKKTEnit.K. 

by  some  surgeons,  seems  to  have  included  a  large  portion  of  one 
or  more  vertebrae:  and  such  removal  appears  to  liave  been 
readily  tolerated. 

In  the  reports  of  operative  work  done  for  relief  in  such  injury, 
the  dura  mater  was  opened  for  the  purpose  of  removing  a  clot  of 
blood,  or  of  restoring  the  continuity  of  the  ruptured  cord.  After 
this  has  been  done,  the  dura  mater  must  be  closed  by  means  of 
fine  catgut  suture. 

The  work  of  rhachitomy  being  completed,  the  wound  is 
to  be  closed,  with  or  without  drainage,  as  the  conditions  may 
demand.  And  should  there  be  danger  of  displacement  of  the 
rectified  spine,  then  immobilization  may  be  done  by  means  of  a 
g3'psum  casement  comprising  the  neck  and  the  upper  part  of  the 
trunk. 

Instead  of  operating  thus  in  tlie  median  line,  the  j^lan  of  a 
Lateral  incision  suggests  itself  to  the  author  in  which  an  incision 
might  be  made  to  the  spine  between  the  transverse  and  spinous 
processes,  and  the  cai5al  being  opened  by  the  aid  of  a  chisel, 
the  spinous  segment  of  the  canal  could  be  reflected  towards  the 
other  side,  and  the  cord  having  been  liberated  from  pressure,  the 
wound  could  be  closed.  The  advantage  of  this  procedure  is  that 
no  bony  structure  would  be  sacrificed.  For,  despite  the  assevera- 
tions of  surgeons  that  no  ill  consequence  results  from  removing 
sections  of  one  or  more  vertebra,  the  avoidance  of  sucli  sacrifice 
would  evidently  be  one  improvement  on  the  usual  method  of 
rhachitomy. 


INDEX 


Abscess,  dental,  733;  treatment,  736;  of 
pharynx,  713;  treatment,  716;  phleg- 
mon of  neck,  853;  treatment,  858;  of 
maxillary  sinus,  393;  treatment,  395; 
of  tongue,  618;  treatment,  620 

Acne  ciliaris,  hordeolum  or  sty,  471; 
treatment,  471 

Adams,  on  malignant  lymphoma,  883; 
deflection  of  septum,  347 

Adelmann,  on  goitre,  839;  foreign  bodies 
in  cesophagus  983 

Adherent  pinna,  296 

Adhesion,  inflammatory,  28;  palatal,  656 

Affections,  of  auditory  canal,  298;  treat- 
ment, 299;  of  carotid  artery,  1098;  of 
external  ear  288;  of  eyebrow  and  eye- 
lid, 455;  of  membranes  of  brain,  210; 
treatment,  214;  of  scalp,  general  clas- 
sification, 14 

Air  passages,  foreign  bodies  in,  955 

Alar  marginal  defect,  421 

Albert,  of  Vienna,  ligation  of  external 
carotid  artery,  1127 

Alquie,  on  concussion  of  brain,  226; 
rhinoplasty,  414 

Alveolar  periostitis;  733;  treatment,  734 

Amussat,  on  hanging,  980;  atresia  of 
mouth,  549 

Amygdalotomy,  tonsillotomy  or  excision 
of  tonsil,  701;  authorities  cited,  702 

Ancelon,  on  hare-lip,  566;  malignant 
pustule,  902 

Anchylosis  of  maxilla  inferior,  764; 
treatment,  765 

Andr6  on  facial  neuralgia,  789 

Andrew,  John  (and  other  authorities)  on 
tracheotomy,  1002 

Anel,  on  ligation  in  aneurismal  tumors, 
117 

Aneurism,  of  scalp,   14;  of  tongue,  650 

Angioma,  in  neck,  869;  treatment,  870; 
on  nose,  336;  treatment,  337;  in  paro- 
tidean  region,  517;  treatment,  518;  in 
scalp,  103 

Aiikyloblepharon,  blepharophimosis  or 
narrowness  of  palpebral  opening,  475; 
treatment,  475 

Ankyloglossa,  or  tongue-tie,  613 

Anstie,  on  facial  neuralgia,  787 

Anthrax,  carbuncle,  893;  diagnosis,  895; 
prognosis,  896;  treatment,  896 


Antrum  of  High  more,  or  maxillary 
sinus,  391;  cj^sts  in,  397;  treatment, 
898;  fistula  of,  396;  treatment,  397 

Aran,  on  fracture  of  cranium,  160;  on 
tonsillitis,  694 

Archambault,  on  tracheotomy,  1051 

Arlt,  on  symblepharon,  477 

Arnold,  on  glossitis,  617 

Arteries,  in  the  scalp,  10 

Artery,  carotid,  affections  of,  1098;  sub- 
clavian, 1127 

Artificial  respiration,  935 

Aspiration,  938 

Astringents,  46 

Atresia,  547;  treatment  of,  548 

Atrophy,  of  scalp,  89 

Auditory  canal,  affections  of,  298;  treat- 
ment, 299;  cerumen  or  foreign  bodies 
in,  301,  303;  occlusion  of,  300;  poly- 
pus in,  301 

Auditory  passage,  hemorrhage  from,  306 

Autenrieth,  on  stricture  of  cesophagus, 
979 

B 

Bain,  on  artificial  respiration,  943 
Baillarger,  on  spasin  of  cesophagus,  975 
Baker,  on  excision  of  tongue,  637 
Balassa,  on  wounds  of  neck,  921 
Ballon,  on  meninges  of  brain,  209 
Bamberger,  on  nasal  injury,  829 
Bardelelaen,  on  cranial   bullet  wounds, 

178 
Bartels,  Max,  on  hare-lip,  559 
Barthez,  on  tracheotomy  in  croup,  1022, 

1029 
Barton,  Ehea,  on  anchylosis,  768 
Battle,  on  fracture  of  skull,  166 
Bauchot,  on  maxillary  fibroma,  754 
Baudens  on  cervical  glandular  tumors, 

884 
Bayford,  on  stricture  of  cesophagus,  979 
Bean,  on  facial  neuralgia,  790 
Beaugrand,  on  luxation  of  maxilla  in- 
ferior, 771 
Beaussenat,  on  purulent  tumor,  348 
Beck,  on  cerebral  concussion,  226 
Becquerel  and  Breschet,  thermo-electric 

tests,  18 
Begin,    on    maxillary    excision,     763; 

spasm  of  cesophagus,  977 
Bell,  on  tonsillitis,  697 
Benedict,  on  facial  neuralgia,  787 
(1167) 


1]68 


INDKX. 


Bc'ran<Ter-Ferraud,  on  nasal  injury,  329 

Benird,  on  neurectomy,  790;  piirotis, 
52-4;  parotidean  tumors,  527 

BeriT,  on  labial  cancer,  600;  lingual 
cancer,  637 

Bersjmann,  on  cranial  bullet  wounds, 
178 

Berhnsfhieri,  Vacca,  on  spasm  of  oesoph- 
agus, 978 

Bernard,  Claude,  on  parotidean  fistula, 
532 

Bert,  Paul,  on  plastic  sun^ery,  449; 
drowning,  947 

Bertherand,  on  wounds  of  neck,  917 

Betz,  on  gunshot  wounds  of  cranium, 
181;  oesophageal  neoplasms,  994 

Beziers,  on  palatal  cleft,  664 

Bichat,  on  cancer,  139;  pathology,  23; 
trepan,  201 

Bidalot,  on  hare-lip,  562 

Bigg,  on  torticollis,  815 

Billroth,  on  inflammation.  18,  2G;  ex- 
tirpation of  larnyx,  1080;  malignant 
lymphoma,  881;  phosphorus-necrosis, 
747;  nasiil  polypus,  352;  staphylorra- 
phy,  675;  excision  of  tongue,  635; 
bullet  wounds  in  cranium,  181 

Bilz,  on  goitre,  829 

Bird,  Golding,  on  nasal  obstruction, 
351 

birkett,  on  external  ear,  288 

Blackley,  on  carbuncle,  900 

Blandin,  on  hare-lip,  578,  nostrils,  345; 
rhinoplasty,  415 

Blasius,  on  anchylosis,  766;  hare-lip, 
579 

Bleeding,  from  nose,  371;  treatment, 
376 

Blepharophimosis,  ankyloblepharon  or 
narrowness  of  palpebral  opening,  475; 
treatment,  475 

Blepharoplasty,  491 

Blood  cvst,  on  neck,  871;  treatment, 
873 

Bluhm,  on  trephination,  104 

Blunienbach,  320;  on  nostrils,  345 

Bochdalek,  on  tumors  of  neck,  866 

Boeckel,  on  hare-lip,  566,  580;  tracheot- 
omy, 1028 

Boinet,  on  cerebral  contusion,  247 

Bonafont,  on  parotidean  fistula,  502; 
phlegmon  and  abscess,  860 

Bones,  nasal  fracture  of,  329;  treatment, 
330 

Bonnet,  on  anchylosis,  767;  carbuncle, 
898;  ectropion,' 482;  goitre,  830;  tor- 
ticollis, 812,  815 

Bouchut,  on  tracheotomy,  1022;  larny- 
gotomy,  1078 

Bf>urdillat,  on  tracheotomy,  1028 

Bourgeois,  on  malignant  pustule,  901 

B'luvier.on  anch}'losis,767;  tracheotomy, 
1025 


Boyer,  on  atresia  of  mouth,  549;  lingual 
prolapsus.  612;  surgery  of  frontal  re- 
gion, 323;  malignant  growths  of 
tongue.  633 

Brain,  concussion  of,  223;  diagnosis, 
230;  prognosis,  231;  treatment,  232; 
compression  of,  234;  diagnosis,  238; 
prognosis,  239;  treatment,  240;  con- 
tusion of,  245;  prognosis,  247;  treat- 
ment, 248;  hydrocephalus,  272;  treat- 
ment, 275;  inflammation  of,  250; 
surgical  atl'ections  of  membranes  of, 
209;  meninges  of,  208;  meningocele 
and  encephalocele,  270;  treatmentj 
272;  microcephalus,  278;  pachymen- 
ingitis, 215;  syphiloma  of,  262;  tu- 
bercle of,  220;"  treatment,  220;  men- 
ingeal tumors  of.  220:  tumors  of,  261 

Brainard,  46;  on  defects  of  spinal  col- 
umn, 1141 

Brasdors  operation,  117 

Bratsch,  on  neurectomy,  792 

Breionneau,  on  tracheotomy,  1025 

Broca,  on  carbuncle,  900;  on  trephining, 

Brown,   Dillon,   on  laryngotomy,  1080 

Brouardel,  on  hanging   930 

Bronchotoin^-,  1000 

Broussais,  17 

Bruns,  on  goitre,  846;  hare-lip,  566, 
578;  hydrocephalus,  277;  laryngotoni}', 
1073;  parotis,  524;  tracheotomy,  1031 

Bryant,  on  injuries  of  brain,  236 

Bryk,  on  ranula,  730 

Buchanan,  on  external  ear,  286;  excision 
of  tongue,  635 

Buc'juoy,  on  phosphorus-necrosis,  745 

Biihring,  on  uranoplasty,  677 

Bulbo-palpebral  union,  or  symblepha- 
ron,  476;  treatment,  477 

Biinger,  on  rhinoplasty,  408 

Burns,  Allan,  on  subclavian  artery,  1129; 
ligation  of  primitive  carotid,  1109; 
eyelid,  468;  parotid  gland,  524;  surgi- 
cal anatomy  of  neck,  802;  malar  and 
parotidean  regions,  524 

Burow,  on  blepharoplasty,  493;  labial 
cancer,  601;  plastic  surgery,  436; 
tracheotomy,  1026 

Busch,  on  benign  tumors  of  parotis,  52C 

Butcher,  of  Dublin,  on  hare-lip,  579; 
resection  of  upper  jaw,  541 


Cancer,  commencement  and  course,  591; 

cause,  594;  labial  598;  statistics,  598; 

scirrhus  and  encephaloid  types,  142; 

treatment,  144 
Cavbuncle,  anthrax,  893;  diagnosis,  895; 

prognosis,  896;  treatment,  896 


INDEX. 


1169 


Carcinoma,  or  cancer,  labial,  590;  diag- 
nosis, 596;  prognosis,  597;  statistics, 
598;  treatment,  599;  in  lower  jaw, 
758;  treatment,  760;  in  parotidean  re- 
gion, 523;  in  scalp,  139;  treatment, 
IM 

Carless,  on  pharyngeal  abscess,  718 

Carnochan,  on  anchylosis,  769;  ligation 
of  primitive  carotid,  1116;  neurec- 
tomy, 794 

Carotid  artery,  affections  of,  1098;  prim- 
itive, ligation  of,  1101,  1120 

Carotid  artery,  external,  ligation  of,  1120 

Casselberry,  on  laryngotomy,  1083 

Catarrh,  nasal,  orozsena,  383;  treatment, 
385 

Cauchois,  on  lipoma  of  tongue,  625 

Cavasse,  on  fracture  of  larynx,  924 

Cavity,  mastoid,  808 

Cay  tan,  on  tonsillitis,  691 

Celsus,  on  cancer,  139,  603;  carbuncle, 
893,  897;  nasal  defect,  422;  foreign 
bodies  in  ear,  308;  nasal  fracture, 
331;  goitre,  825,  828;  inflammation, 
88;  fracture  of  lower  jaw,  778;  luxa- 
tion of  inferior  maxilla,  770;  pathol- 
ogy, 23;  nasal  polypus,  356;  rhino- 
pTastj^,  408;  plastic  surgery,  434;  trep- 
anation, 187 

Cerumen,  or  foreign  bodies  in  auditory 
canal,  301 

Cervical  glands,  sarcoiBa  of,  874;  treat- 
ment, 880;  vertebrae,  luxation  of,  1144 

Chabdon,  on  trephination,  198 

Chalazion,  or  gelatinous  or  fibrous  tumor 
of  eyelid,  471;  treatment,  472 

Championniere,  on  trephination,  191 

Charcot,  26;  on  pachymeningitis,  214; 
trephination,  190 

Chassaignac,  on  ligation  of  external 
carotid  artery,  1126;  concussion  of 
brain,  225;  foreign  bodies  in  air  pas- 
sages, 957;  phlegmon  and  abscess,  860; 
prominent  septum,  346;  tonsil,  688; 
tracheotomy,  1126 

Chatin,  on  goitre,  832 

Chaym,  of  Berlin,  on  tracheotomy,  1033 

Cheek,  wounds  of,  504 

Cheever,  on  tonsillar  tumors,  711 

Chelius,  on  goitre,  839 

Chiari,  on  epistaxis,  378 

Chiene,  on  pharyngeal  abscess,  717 

Cicero  on  tongue-tie,  613 

Clark's  device  in  tracheotomy,  1019 

Clarke,  Farlie,  on  lingual  prolapsus, 
612;  fibroma  of  tongue,  626 

Cleft-lip,  hare-lip,  or  labium  leporinum, 
555;  double,  675;  operation,  566,  575 

Clefts,  congenital  or  fistuhe  in  neck,  819; 
treatment,    822;    palatal,  659;    treat- 
ment, 663 
C16mot,  on  hare-lip,  568 
Cloquet,  on  staphylorraphy,  665 
Cohn,  of  San   Francisco,  treatment  of 
paralysis  from  diphtheria,  1065 


Cohnheim,  on  inflammation,  18,  26 
.  Coindet,  on  goitre,  835 
CoUes,  on  carbuncle,  898;  subclavian  ar- 
tery, 1129;  excision  of  tongue,  642 
Collin,  on  goitre,  833 
Collis,  on  fibrous  polypus,  366 
Comparetti,  on  external  ear,  286 
Compression   of  brain,    234;    diagnosis,. 

238;  pi-ognosis,  239,  treatment,  240 
Compte,  Auguste,  20 
Concretion,    salivary,    516;    treatment, 

517 
Concussion  of  brain,  223;  diagnosis,  230; 

prognosis,  231;  treatment,  232 
Condensation,  inflammatory,  28 
Conditions  for  ti'ephining,  240 
Congenital   deformity,   of   e_yelid,   489; 
treatment,   489;    of  maxilla   inferior, 
733;  treatment,  734;  defects  of  oesoph- 
agus,   961;    of  spinal    column,    1139; 
treatment,  1141;   clefts  in  neclc,  819: 
treatment,  822 
Constitutional  tumors  in  brain,  219 
Constrictive  agents,  4G 
Contusion  of  brain,  245;  prognosis,  247; 

treatment,  248;  of  scalp,  65 
Cook,  on  carbuncle,  896 
Cooper,  Sir  A.,  on  palatal  adhesion,  657; 
subclavian  artery,  1128;  treatment  of 
.  cystoma,  95;  of  erysipelas,  46;  fungous 
nasal  tumor,  349;  ligation  of  primi- 
tive ^arotid,  1108 
Cooper,  E.  S. ,  on  goitre,  839;  vi^ounds  of 

internal  jugular  vein,  1138 
Cooper,  Samuel,  on  tonsillotomy,  702 
Coote,  Holmes,  on  nasal  injur}^,  329 
Copland,  on  carbuncle,  anthrax,  895 
Cornil,  on  epithelioma  of  brain,  218 
Costes  of  Bourdeaux,  on  pneumatoceph- 

alus,  312 
Couper,  on  tracheotomy,  1030 
Couty,  of  Paris,  on  wounds  of  intern:il 

jugular  vein,  1137 
Crampton,  Sir  Philip,  on  entropion,  488 
Cranium,    152;   fracture  of,  159;    treat- 
ment, 166;  traumatic  lesions  of,    153; 
gunsliot  wounds  of,   172;    treatment, 
179;  incised  wounds  of,  157 
Crawfoot,  on  fracture  of  vertebrse,  1162 
Crean,  on  phlegmon  and  abscess,  860 
Crespi,  on  cranial  gunshot  wounds,  173 
Criquy,  on  pharynx  and  oesophagus,  983 
Croly,  on  carbuncle,  895 
Cruveilhier,  on  cancer,  140 
Cutaneous    transplantation,    Thiersch's 

method,  449 
Cusco,  on  ankyloblepharon,  476 
Cystic  growths,  of  tongue,  624;  tumors, 

maxillo-dental,  748;  treatment,  752 
Cystoma,  labial,  589;  in  scalp,  93 
Cysts,  in  antrum,  397;   treatment,  398; 

in  oesophagus,  991 
Czermak,  on  staphylorraphy,  674 
Czerny,  on  oesophageal  neoplasms,  997; 
on  extirpation  of  larynx,  1086,  1093 


1170 


INDEX. 


Darby,  on  phlegmon  and  abscess,  860 

Dassen,  on  ranula,  727 

Davahie,  on  malignant  pustule,  902 

Davies-CoUey,  on  uranoplasty,  683 

De  Chauliac,  Guy,  on   trephining-,  201 

De  Gattery,  Mirza  A.  V.,  on  parotidean 

fistula,  530 
Deguise,  on  parotidean  fistula,  531 
Defect,  alar  margin,  421 
Defects,   of  ear,    288;  of  external   ear, 
297;  of  nose  and  nasal  passages,  327; 
from  loss   of  side  of  nose,  including 
alar  margin,  421 
Deflection  of  nasal  septum,  346;  treat- 
ment, 847 
Deformities,  of  eyelid,  congenital,  489; 
treatment,    489;  of  maxilla    inferior, 
733;  nasal,  402;  palpebral,  473;  treat- 
ment,  473;  of  tongue, 609 
Delore,  on  torticollis,  809 
Delorme,  on  epithelioma  in  parotis,  522; 

parotidean  tumors,  527 
Delstanche,   on   occlusion   of   auditory 

canal,  300 
Demarquay,  on  malignant  lymphoma, 
883;  maxillary  resection,  543;  on  ex- 
cision of  tongue,  634,  638;  malignant 
growths  of  tongue,  633;  tracheotomy, 
1010 
Demme,  184;  on  glossitis,  615,  617 
DeMorgan,  Campbell,  on  torticollis,  813 
Denonvilliers,    on  ectropion,  484;  hare- 
lip, 566;  nasal  defect,  421 
Dental  abscess,  733;  treatment,  736 
Denuc^,  on  wounds  of  palate,  650 
Depaul,  on  insufflation,  937 
Desarenes,on  mastoid  cavity,  310 
Desault,  on  goitre,  840;  hare-lip,    579; 

laryngotomy,  1070 
Deschenais   on  tracheotomy,  1019 
Despr^s,  on  carbuncle,   898;  nasal   de- 
formity, 405 
Desterne,  on  facial  neuralgia,  789 
Destruction  of  uvula  and  soft  palate,  657 
Deviation  of  oral  opening,  553 
Devergie,  on  drowning,  947 
Dezanneau,  and  other  authorities,  on  fi- 
brous polypus,  368 
Di  Carpi  Berenger,  on  trephination,  200 
Dieflfenbach,  on  alar  margin  defect,  422; 
palpebral  deformities,  474;  ectropion, 
480,  485;  labial  ectropion,  554;  goitre, 
hare-lip,  567;  atresia  of  mouth,  650; 
fibrous  polypus,  368;  trephining  mas- 
toid process,  308;  maxillary  resection, 
539;  rhinoplasty,    412,     415;    staphv- 
lorraphy,  666,  673;  tonsillotcmiy,  703; 
torticollis,     811;     uranoplast}-,      677- 
wounds  of  neck,  917 
Dion  is,    on   ranula,    729;   tonsillotomy, 

702 
Diseases  of  eyelid,  471 
Disintegrants,  46 


Dispersion,  immediate  or  retarded,  in- 
fianunatory,  27 

Dolbeau,  on  phlegmon  and  abscess,  857; 
osseous  growths,  320 

Drowning,  946;  eminent  medical  au- 
thorities on,  946 

Dublin,  on  hare-lip,  579 

J)ul)ois,  on  hare-lip,  563 

Duchenne,  on  malignant  lymphoma, 
883;  torticollis,  809 

Dumesth^,  on  phlegmon  and  abscess, 
857 

Duplay,  on  fistulse  in  neck,  820;  hsera- 
orrhage  from  auditory  passage,  306; 
nasal  polypus   359 

Dupuytren,  on  compression  of  brain, 
245;  contusion  of  brain,  246;  on  hare- 
lip, 563;  tonsillotomy,  702;  vesica- 
tion, 47,  234 

Dura  mater,  tumors  of,  216;  classes  of, 
217 

Duret,  of  Paris,  on  concussion  of  the 
brain,  227 

Durham,  on  foreign  bodies  in  nose,  382; 
nasal  polypus,  354;  tracheotomy,  1005 

Dusch,  on  tracheotomy,  1028 

Duval,  on  torticollis,  804,  812 


Eai',  external,  defects  and  affections  of, 
288;  att'ections  of  auditory  canal,  298; 
mastoid  cavity,  308;  treatment,  299; 
occlusion  of  auditory  canal,  300;  by 
polypus,  301;  by  cerumen  or  foreign 
bodies,  301;  adherent  pinna,  296; 
hfemorrhage  from  auditory  passage, 
306;  othematoma,  291;  treatment, 
293;  rents,  fissures,  and  loss  of  struc- 
ture, 297;  emphysema  or  pneumato- 
cephalus,  311;  treatment,  312;  surgery 
of  the  ear,  285;  wounds  of,  290;  treat- 
ment, 291 

Ecker,  on  goitre,  826 

Eckholdt,  on  spasm  of  oesophagus,  977 

Ectropion,  of  eyelid,  478;  labial,  654 

Eigenbrodt,  on  hare-lip,  564 

Elements  of  plastic  surgery,  427 

Elliott,  on  wounds  of  intei-nal  jugular 
vein,  1137 

Emphysema,  or  pneumatocephalus  orig- 
inating behind  the  ear.  311;  treat- 
ment, 312;  of  eyelids,  469;  in  scalp, 
145 

Encephalitis,  or  inflammation  of  brain, 
250;  causes,  250;  symptoms,  252;  di- 
agnosis, 255;  treatment,  257 

Encephalocele,  meningocele,  270;  treat- 
ment, 272 

Entropion,  486 

Epicanthus,  490;  treatment,  491 

Epithelioma,  of  brain,  218;  in  paroti- 
dean region,  522;  in  scalp,  131;  treat- 
ment. 135 


INDEX. 


1171 


Epulis,  of  maxilla  inferior,  755;  treat- 
ment, 757 

Erichsen,  on  wounds  of  internal  jugu- 
lar vein,  1137 

Erysipelas,  38;  treatment,  44;  remedies, 
46,  48;  in  ej-elid,  467 

Eseharotics,  47 

Esmarch,  on  anchylosis,  768;  hare-lip, 
579 

Estlander,  on  gunshot  wounds  of  the 
cranium,  177 

Eulenberg,  on  torticollis,  814 

Everbusch,  on  plastic  surgery',  451 

Excision  of  tonsils,  701 

Exophthalmic  goitre,  847 

External  carotid  artery,  ligation  of,  1120; 
jugular  vein,  ligation  of,  1181 

External  nose,  growths  aflecting,  334 

Extirpation  of  larynx,  1086 
.Eye,  foreign  bodies  in,  500;  treatment, 
501 

Eyebrow,  surgical  aflection  of,  455 

Eyelid,  surgical  aifection  of,  455;  anky- 
loblepharon, 475;  treatment  475; 
blepharoplasty,  491;  burns  on,  468; 
chalazion,  or  gelatinous  or  fibrous 
tumor  of,  471;  treatment,  472;  con- 
genital deformities  of.  489;  treatment, 
489;  affections  of,  471;  ectropion, 
478;  emphysema,  469;  entropion, 
486;  epicanthus,  490;  treatment,  491; 
erysipelas  in,  467;  foreign  bodies  in 
eye,  500;  treatment,  501;  hordeolum, 
acne,  ciliaris  or  sty,  471;  treatment, 
471;  palpebral  deformities,  473;  treat- 
ment, 473;  symblepharon,  or  bulbo- 
palpebral  union,  476;  treatment,  477; 
tumors  arising  from  orbital  wall,  494; 
treatment,  495;  tumors  originating 
within  orbit,  496;  wounds  o^,  463 


Eabricius,  on  luxation  of  maxilla  infe- 
rior, 773;  symblepharon,  477 

Eace,  wounds  of,  504;  parotidean  region 
of,  509 

Eacial  neuralgia.  783 

Fallopius,  on  flap  wounds  of  cranium, 
158 

Pano,  on  concussion  of  brain,  225 

Earabeuf,  on  rhinoplasty,  413;  ligation 
of  external  carotid  artery,  1126 

Eaure,  on  strangulation,  926 

Eergusson,  Sir  William,  on  anchylosis, 
767;  plastic  surgery,  448;  staphylor- 
raphy,  671;  uranoplasty,  680 

Eerrier,  on  trephining,  190 

Eibrinous  tumor  of  eyelid,  471;  treat- 
ment, 472 

Fibroma,  of  maxilla  inferior,  754;  of 
tongue.  626 

Fibrous  polypus,  360;  treatment,  364 

Eirst  method  in  plastic  sai-gery,  430 


Fisher,  on  wounds  of  internal  jugular 
vein,  1138 

Fisher,  on  pharyngeal  tumors,  722 

Fissures,  rents, "and  defects  of  external 
ear,  297 

Fistulae  in  neck,  819;  treatment,  822 

Fistula  of  antrum,  396;  treatment,  397; 
of  neck,  819;  parotidean,  528;  treat- 
ment, 529 

Fleischmann,  on  hanging,  930 

Flourens,  on  trephining,  190 

Fock,  on  tracheotomy,  1022 

Foreign  bodies  or  cerumen  in  auditory 
canal,  301,  303;  in  air  passages,  955; 
in  eye,  500;  treatment,  501  ;"in  nasal 
passages,  380;  in  pharynx,  723;  in 
tongue,  644;  in  pharynx  and  oesopha- 
gus, 982 

Forget,  on  maxillar_^   excision,  762 

Fouilloux,  on  epulis    756 

Foulis,  of  Glasgow  on  extirpation  of 
larynx,  1095 

Fournier,  on  ozaena,  384 

Fowler's  solution,  129 

Frabrieius,  on  sjmiblepharon,  477 

Fracture,  of  nasal  bones,  329;  treatment, 
330;  of  cranium,  159;  treatment,  166; 
of  hyoidbone,  922;  treatment,  923;  of 
larynx,  923;  symptoms,  treatment, 
924;  of  maxilla"  inferior,  775;  treat- 
ment, 778;  maxilla  superior,  533;  of 
vertebra?,  1150 

Fracv,  on  ligation  of  external  carotid, 
1126 

Frankel,  on  oz^na,  384,  387 

Fredericq,  on  nasal  polypus,  359 

Fricke,  method  of,  in  blepharoplasty, 
491 

Fritsch,  on  hare-lip,  564;  on  trephining, 
190 

Fritz,  on  gunshot  wounds  in  cranium, 
177 

Fuller,  on  tracheotomy,  1021 


G 


Gaillard,  on  entropion,  487 

Galen,  on  meninges  of  brain,  208;  lin- 
gual prolapsus,  612;  nasal  injury,  329; 
tonsillitis,  694 

Gamgee,  on  excision  of  tongue,  635 

Gangrene,  36;  of  scalp,  82 

Garre,  on  goitre,  841,  874 

Garwood,  60 

Gay,  on  staphylorraphy,  674 

Gelatinous  tumor  of  eyelid,  471;  treat- 
ment, 472 

Gensoul,  on  maxillary  resection,  539 

Germicidal  agents,  48 

Gherini,  on  ligation  of  external  carotid 
artery,  1126 

Gillette,  on  retro-pharyngeal  abscess,  713 

Gingivitis,  of  maxilla  inferior,  733 

Gintrac,  on  meningeal  tumors,  217;  par- 
asitic tumors,  219 


1172 


INDKX. 


Giraldes,  on  cysts  in  the  antrum,  o!t8; 
liare-lip,  5G6 

Glands,  cervical,  sarcoma  of.  874;  treat- 
ment of,  880;  thyroid,  823 

Glossitis,  or  inflammation  of  tongue,  615; 
treatment,  617 

Godefroy,  on  harelip,  563 

Goitre,  medical  treatment,  835;  sursjical 
treatment,  838;  exophthalmic,  847 

Gosselin,  on  carhunele,  898;  erysipelas, 
145;  wounds  of  neck,  918 

Gottstein,  on  oztena,  387 

Goursauld.on  stricture  of  oesophagus,  976 

Goux,  on  neurectomy,  793 

Graefe,  on  lahial  cancer,  600;  palpehral 
deformities, 474;  ectropion,  480;  entro- 
pion, 489;  hare-lip,  568;  rhinoplasty, 
420;  foreiijn  hodies  in  (esophagus,  984 

Graser,  on  plastic  surgery,  451 

Greene,  Warreii,  on  goitre,  840 

Gresswell,  on  tracheotomy,  1033 

Griesinger,  on  cerehral  concussion,  231 

GrisoUe,  on  tracheotomy,  1029 

Gross,  on  foreign  bodies  in  air  pas- 
sages, 956;  nasal  polypus,  357;  wounds 
of  internal  jugular  vein,  1134 

Growths,  lahial,  585;  treatment  586; 
lahial  cancer,  590;  lahial  cystoma, 
589;  in  parotid  gland,  521;  in  lower 
jaw,  758;  in  inferior  maxilla,  748; 
solid,  of  neck,  873;  affecting  external 
surface  of  nose,  334;  parotidean,  515; 
in  scalp,  121;  vascular,  in  scalp,  114; 
in  tongue,  622;  treatment,  623;  cystic, 
of  tongue,  624-  malignant,  of  tongue, 
626;  diagnosis    631;  treatment,  623 

Gruber,  on  polypus  of  ear,  301;  on 
tracheotomy,  1017 

Griinmach,  on  goitre,  837 

Grynfelt,  on  goitre,  833 

Gu^rin,  on  anchylosis,  767;  carbuncle, 
897,  898;  ectropion,  482;  fracture  of 
superior  maxilla,  534;  torticollis,  811 

Guersant,  on  hare-lip,  566;  tonsillotomy, 
704;  tracheotomy,  1019,  1052 

Gueterhock,  on  tracheotomy.  1028 

Guilbourt,  on  maxillo-dental  cystic  tu- 
mors, 748 

Guillier,  on  excision  of  tongue,  636 

Gummy  periostitis  in  pericranium,  149 

Gunshot  wounds,  general   remarks,  72; 
of  cranium,  172;  of  scalp  and  skull, 
75;  treatment,  179 
Gurlt,  on  cranial  wounds,  177;  tracheot- 
omy, 1005. 
Gussenbauer,  on  anchylosis,  766;  extir- 
pation of  larynx,  1095 
Guthrie,  r)n  flapwounds  of  scalp,  158 
Gutzeit,  on  carhunele,  896 


H 


Haas,  on  concussion  of  brain,  225 
Habicot,on  foreign  bodies  in  oesophagus, 
985 


IlicMiorrluige,   163; 'from    auditory  ])as- 
sage,  306;   from  nose,  371;   treatment, 
376;  authorities  cited,  307 
Hall,  Marshall,  on  artiticial  respiration, 

939 
Ilaller,  on  ranula,  727 
JIaltenhoff,  on  phosphorus-necrosis,  745 
llamhurger,  on  goitre,  839;  stricture  of 

a'st>phagus,  971 
Hamilton,  on  hare-lip,  566 
Hanging,  929;  aspiration,  938;  insuffla- 
tion, 935;  artiticial  respiration,  935 
Hare-lip,  555;  operation  on,  566;  double, 

575;  operation  on,  575 
Hardy,  on  tracheotomy,  1021 
Harrison,  on  excision  of  tongue,  635 
Hasner,  on  blepbaroplasty,  492 
llaunieder,  on  fracture  of  lai-ynx,  923 
Hasse,  on  surgery  of  ear,  292;  tracheot- 
omy, 1030 
Haworth,  on  concussion  of  brain,  224 
Hayem,  on  encephalitis,  251 
Hecker,  on  fracture  of  vertebra?,  1161 
Hedenus,  on  ozajna,  388,  386 
Heise  on  goitre,  830 
Heister,  on  tonsillotomy,  702 
Henle,  on  meninges  of  brain,  208 
Henri,  on  hare-lip,  569 
Hensinger,  on  fistula  in  neck,  819 
Hermann,  on  hare-lip,  564 
Herpin,  on  tonsillitis,  697 
Hervier,  on  orbital  tumor  499 
Heurtaux,  on  inflammation,  16 
Heurteloup,  on  hare-lip   580 
Heyfelder,  on  excision  of  lower  jaw,  761, 
763;  maxillary  resection,  539;  orbital 
tumor,  499 
Highmore,  antrum  of,  391;  see  maxillary 

sinus 
Hilton,  on  parotitis,  515 
Himly,  on  symblepharon,  477 
Hippocrates,  on  erysipelas,  38;  luxation 
of  inferior  maxilla,  770;    fracture  of 
lower  jaw,  778;    nasal  fracture,  352, 
355;   on  tonsillitis,    694;    trepanning, 
186;  trephining,  200 
Hitzig,  on  trephining,  190 
Horta,  on  goitre,  846' 
Hofl'man,  on  drowning,  947;  strangula- 
tion, 92G,  930,  934 
Hordeolum,   acne  ciliaris,  or  sty,  471; 

treatment,  471 
Horsley,  on  intra-cranial  tumor,  269 
Howard's   method   in  artificial  rc>])ira- 

tion,940 
Huljer,  on  laryngotomy,  1080 
Hiibscher,  on  plastic  surgery,  451 
Hueter,   on  ligation  of  lingual  artery, 
639;    laryngotomy,  1076;    extirpation 
of  larynx,  1095;    tracheotomy,  1026; 
luxation  of  cervical  vertebrae,  1147 
Iluguier,  on  excision  of  lower  jaw.  761 
Humphrey,  on  lingual  prolapsus,  613 
Hunt,  on  tracheotomj',  1005 


INDEX. 


1173 


Hunter,  John,  on  cancer,  140;  carbuncle, 
894;  ligation  of  vascular  growths,  117; 
inflammation,  36;  contusion  of  scalp, 
70;  wounds,  50,  74 

Hutchinson,  on.  compression  of  brain, 
238 

Hiiter,  on  tracheotomy,  1030 

Hydrocephalus,  272;  treatment,  275 

Hyoid  bone,  fracture  of,  922;  treatment, 
923 

Hvpertrophv,  labial,  553;  treatment, 
o53;  lingual,  610;  treatment,  611;  of 
tiasal  mucous  membrane,  370;  of  scalp, 
88;  of  tonsil,  697;  treatment,  700; 
authorities  cited,  699 

Hyrtl,  9,  15;  on  mastoid  cavity,  310; 
"nasal  fracture,  330;  external  nasal 
growths,  334;  parotid  gland,  524;  rhi- 
noplasty, 412;  wounds,  62 


I 


Immisch,  on  salivary  concretion,  516 

Incised  wounds,  51;  of  cranium,  157 

Inert  agents,  46 

Infantile  sanguineous  tuinor,  119 

Inferior  maxilla,  732;  surgical  anatomy 
of,  732;  congenital  deformity  of,  733; 
treatment,   734,  736;  growths  in,  748 

Inflammation,  adhesion  from,  28;  of 
brain,  250;  causes,  250;  symptoms,  252; 
diagnosis,  255;  treatment,  257;  in- 
flammation ending  in  condensation, 
28;  defined  and  discussed,  15;  in  dis- 
pei-sion,  immediate  or  retarded,  27; 
mortification,  36;  inflammation  of  pal- 
atal structures,  647;  treatment,  648; 
suppuration.  29;  of  tongue  or  glossitis, 
615;  inflammation  causing  ulceration, 
33 

Inflammatorv'affections  of  parotid  gland, 
513 

Injury,  to  nasal  passages,  328 

Insufflation,  935 

Intra-cranial  tumor,  261 ;  svmptoms  of, 
263;  syphiloma,    262;  treatment,  267 

Intubation,  1078 

Ipsen,  on  tracheotomy,  1032 

Jtard,  on  foreign  bodies  in  auditorv 
canal,  305 

Iversen,  Axel,  on  excision  of  tongue, 
636 


Jaccoud.  on  tumors  of  dura  mater,  217; 

epistaxis,  373 
Jaesche,  on  anchylosis,  768 
James,  on  carbuncle,  894:  on  tonsillitis, 

693 
Janskowski,  on  goitre,  844 
Jasser,  on  mastoid  cavity,  308 
Jaw,  lower,  necrosis  of,  738 
•Jearsley,  on  palatal  malfomiations,  653 
Joal,  on  tonsillitis,  693 


Jobert,  on  goitre,  840;  narrow  nostrils, 
345;  ranula,  729 

Jones,  Sydney,  on  oesophageal  neo- 
plasms, 998 

Jones,  T.  Wharton,  on  ectropion,  482 

Jordan,  on  compression  of  brain,  242 

Junker,  on  tonsillotomy,  702 

Jurasz,  on  deflection  of  nasal  septum,  348 

Jugular  vein,  external,  ligation  of, 
1131;  internal,  wounds  of,  1132 

K 

Kapesser,  on  foreign  bodies  in  air  pas- 
sages, 957 
Kaufmann,  on  goitre,  830 
Keene,  281;  on  intracranial  tumor,  269 
Knapp,  on  symblepharon,  477 
Koch,  Robert,  on  tuberculin.  339 
Kocher,  on  goitre,  841,  845;  ligation  of 
external   carotid    arteiy,    1126;    exci- 
sion of  tongue,  637 
Kijlliker,  on  maxillary  resection,  542 
Konig,  on  tracheal  aspiration,  944;  nasal 

deflection,  423;  tumors  of  neck,  864 
Korber,  of  Dorpal,  on  tracheal  aspira- 
tion, 943 
Korte,  on  tracheotomy,  1032 
Kaske,  on  tracheal  aspiration,  944 
Krevser,  on  foreign  bodies  in  oesopha- 
gus, 984 
Krimer,  on  uranoplasty,  677 
Krishaber,  on  laryngotomy,  1077 
Kroll,  on  tracheotomy,  1030 
Kronlein,   on  pharyngotomy,   722;  tre- 
phining, 196 
Kiister,  on  cranial  bullet  wounds,  178; 
pharyngotomy,  722 


Labadie-Lagrave,  on  tumors  of  dura 
mater,  217 

Labial,  cancer,  590;  cause,  594;  com- 
mencement and  course,  591:  diagno- 
sis, 596;  prognosis,  597;  statistics,  598; 
treatment,  599;  labial  cystoma,  589; 
labial  ectropion,  554;  labial  growths, 
585;  treatment,  586;  labial  hypertro- 
phy, 553;  treatment,  553 

Labium  lepornium,  hare-lip  or  cleft-lip, 
555;  operation,  566;  double,  575; 
operation,  575 

Lacerated  wounds,  60 

Lamballe,  Jobart  de,  on  foreign  bodies 
in  air  passages,  955 

Lancereaux,  on  pachymeningitis,  211 

Lane,  on  wounds  of  internal  jugular 
vein,  1137 

Lang,  on  tonsillar  tumors,  711 

Langenbeck,  111;  on  tracheal  aspiration, 
945;  palatal  chondroma,  651;  paroti- 
dean  fistula,  532:  goitre,  839;  hare-lip, 
566,  570;  hydrocephalus,  277:  fibrous 
polypus,    367;     maxillary    resection, 


1174 


INDEX. 


541;  rhinoplasty,  414;  staphylorniphy, 
669,  675;  excision  of  tongue,  637; 
malignant  growths  of  tongue,  632; 
tracheotomy,  10U5,  1039;  jiharyngcul 
tumors,  722;  tonsillar  tumors,  711; 
uranoplasty,  678;  cranial  bullet 
wounds,  178;  flap  wounds,  159 

Lannelogue,  281;  on  hare-lip,  562; 
uranoplasty,  682 

Lanphear,  on  intra-cranial  tumor,  269 

Larghi,  on  tonsillotomy,  703 

Larrey,  on  cervical  glandular  tumors, 
884 

Laryngectomy,  operation  of,  1086 

Laryngotomy,  1069;  operation  of,  1075; 
intubation,  1078 

Larynx,  fracture  of,  923;  symptoms, 
924;  treatment,  924;  extirpation  of, 
1086 

Laugier,  on  contusion  of  brain,  247; 
hanging,  929;  lipoma  of  tongue,  625; 
strangulation,  925;  trephining,  242 

Lawson,  on  concussion  of  brain,  225 

Le  Bail,  on  hasmorrhage  from  auditory 
passage,  306 

Le  Blanc,  on  lingual  prolapsus,  612 

Le  Dentu,  on  carbuncle,  898 

Le  Fort,  Leon,  on  carbuncle,  898;  tre- 
phination, 195,  242 

Leheribel,  on  fracture  of  maxilla  supe- 
rior, 534 

Lehmann,  on  maxillary  resection,   642 

Lesions  traumatic,  of  cranium,  153 

Leser,  of  Halle,  on  trephination,  190 

Leyden,  on  compression  of  brain,  experi- 
ments, 235 

Ligation  of  primitive  carotid,  1101; 
both  primitive  carotids,  1120;  of  ex- 
ternal carotid  artery,  1120;  of  external 
jugular  vein,  1131 

Lingual  prolapsus  with  hypertrophy, 
6i0;  treatment,  611 

Linn,  on  trephination,  206 

Lipoma,  in  scalp,  99 

Lips,  544;  atresia  of,  547;  treatment, 
548;  hare-lip,  555;  double,  575;  mac- 
rostoma  of,  550;  treatment,  552 

Lisfranc,  on  rhinoplasty,  415 

Liston,  on  staphj'lorraphy,  673 

Littlewood,  on  cervical  glandular  tu- 
mors, 891 

Lizars,  on  maxillary  resection,  542 

Lombard,  on  facial  neuralgia,  789 

Lorinser,  on  phosphorus-necrosis,  743, 
747 

Louis,  on  parotidean  fistula,  531;  lin- 
gual prolapsus,  612;  tracheotomy 
bronchotomy,  1002 

Liicke,  on  maxillary  resection,  541;  su- 
perficial germicidal  treatment,  48; 
tracheotomy,  1026 

Ludlow,  on  carbuncle,  894,  898 

Lupus,  338;  treatment,  339;  rodens, 
341;  treatment,  342 


Luton,  on  goitre,  837 

Luxation,    of    maxilla     inferior,    770; 

treatment,  773;  of  cervical   vertebrae, 

1144 
Lymph-angioma,  in  neck,  867 
Lymphatic  vessels  and  glands  of  scalp 

'll 
Lymphoma,  malignant,  877 


M 


MacClellan,  on  parotidean  operations, 
528 

Macewen,   on  intra-cranial  tumor,  269; 

MacKenzie,on  labial  cancer,  603;  oesoph- 
ageal neoplasms,  995 

Macrostoma,  of  lips  550;  treatment, 
552 

Madelung,  on  tracheotomy,  1032 

Magitot,  on  maxillary  cysts,  748 

Maisonneuve,  on  nasal  defect,  327;  lin- 
gual prolapsus,  612;  growths  of 
tongue,  622;  lipoma  of  tongue,  625; 
tonsillotomy,  703;  tracheotomy,  1025 

Maiweg,  on  labial  cancer,  598 

Malar  and  parotidean  regions  of  face, 
503;  surgery  of,  503 

Malar  region,  scrofulous  ulcer  of,  508; 
treatment,  509;  wounds  of  cheek  and 
side  of  face,  504;  see  parotidean  re- 
gion 

Malformations,  of  palate,  652;  treat- 
ment, 653 

Malgaigne,  on  nasal  defect,  423;  hare- 
lip, 569;  hydrocephalus,  277;  facial 
neuralgia,  789;  parotis,  524;  torticol- 
lis, 806,  816;  luxation  of  cervical  ver- 
tebrae, 1148 

Malignant  growths,  of  parotid  gland, 
521;  in  lower  jaw,  758;  tumors  of 
parotis,  523;  in  scalp,  121;  of  tongue, 
626;  diagnosis,  631;  treatment,  633 

Manec,  on  salivary  concretion,  517 

Mann,  of  Avignon,  on  fibrous  polypus, 
368 

Marchand,  on  insufflation,  936' 

Marchal,  wounds  of  internal  jugular 
vein,  1136 

Marchant,  on  trephining,  196 

Marjolin,  on  carbuncle,  898 

Marks,  pigment,  120 

Martin,  on  oz;ena,  384;  pharynx  and 
oesophagus,  983 

Martino,  on  external  ear, -288 

Mason,  on  lipoma  of  tongue,  625;  on 
staphylorraphy,  675 

Maslieurat-Lag6mard,  on  tracheotomy, 
1018 

Mastoid  cavity,  308 

Math6,  on  anchylosis,  769 

Mathieu,  on  extraction  of  foreign  bodies 
from  oesophagus  and  stomach  986 

Maunoir,  on  goitre,  829;  tracheotomy, 
1025 


INDEX. 


1175 


Maxilla  inferior,  732;  surgical  anatomy 
of,  732;  anchylosis  of,  764;  treatment, 
765;  carcinoma  in,  758;  treatment, 
760;  congenital  deformity  of,  733; 
treatment,  734,  736;  epulis  of,  755; 
treatment,  757;  fibroma  of,  754;  frac- 
ture f  f,  775;  treatment,  778;  growths 
in,  748;  malignant  growths  in,  758; 
necrosis  of  lower  jaw,  738;  prognosis, 
741;  treatment,  741;  luxation  of,  770; 
treatment,  773;  odontoma,  752;  treat- 
ment, 753;  osteoma,  75.5;  alveolar 
periostitis,  733;  treatment,  734;  ill  po- 
sition of  wisdom  teeth,  736;  treat 
ment,  738;  maxillo-dental  cystic  tu- 
mors, 748;  treatment,  752 

Maxillo-dental  cystic  tumors,  748;  treat- 
ment, 752 

Maxillary  sinus,  or  Antrum  of  High- 
more,  391;  abscess  of,  393;  treatment, 
395;  cysts  in  antrum,  397;  treatment, 
398;  fistula  of  antrum,  396;  treatment, 
397 

Maxilla  superior,  533;  fracture  of,  533; 
resection  of  upper  jaw,  536 

Melzer,  on  labial  cancer,  598 

Membranes  of  brain,  epithelioma  in, 
220;  surgical  afi'ections  of,  209;  oste- 
oma, 218;  psammoma  in,  219;  syphi- 
loma in,  220;  tubercular  disease  of, 
220;  constitutional  tumors,  219;  para- 
sitic tumors  in,  219 

Meningeal  tumors,  effects  of,  220;  treat- 
ment, 221 

Meninges  of  brain,  208 

Meningocele  and  encephocele,  270;  treat- 
ment, 272 

Menzel,  on  excision  of  tongue,  635 

Mercier,  on  wounds  of  internal  jugular 
vein,  1136 

Mestivier,  on  tonsillitis,  694 

Mettauer,  on  staphylorraphy,  673 

Metzler,  on  phlegmon  and  abscess,  862 

Meyer,  Ludwig,  on  othsematoma,  292; 
malignant  lymphoma,  883 

Michaux,  on  maxillary  resection,  539 

Michel,  on  neurectomy,  793;  on  ranula, 
730 

Michon,  in  wound  of  carotid  arterv, 
1100 

Mickulicz,  on  tonsillar  tumors,  Til 

Microcephalus  L,  C.  Lane's  treatment 
of,  278 

Millet,  on  tracheotomy,  1026 

Mirault,  on  ectropion,  480;  hare-lip, 
566,  569 

Moleschott.  on  deflection  of  septum,  347 

Molliere,  of  Lvons,  on  fracture  of  ver- 
tebra, 1150  " 

Morax,  on  tracheotomy,  1043 

Morian,  on  hare-lip,  562 

Mortification,  36;  of  scalp,  82 

j^Ioscati,  on  tonsillotomy,  702 

Mosso  Angelo,  on  defects  of  oesophagus, 
961 


Mouth  and  oral  cavity,  544;  atresia  of, 
547;  treatment,  548;  labial  ectropion, 
554;  labial  hypertrophy,  553;  treat- 
ment, 553;  hare-lip,  or  labium  lepo- 
rinum,  556;  operation  on,  566;  deform- 
ity of  oral  opening,  552;  lips,  544; 
macrostoma  of  lips,  550;  roof  of  mouth 
644 

Mucous  membrane,  nasal  hypertrophv 
of,  370 

3Iuseux,  on  tonsillotomy,  702 

Miitter,  on  anchylosis,  766;  epulis,  757; 
foreign  bodies  in  oesophagus,  985,  986 


N 


Narrowness  of  nostrils,  343;  of  palpe- 
bral opening,  475;  treatment,  475 
Xasai  bones,  fracture  of,  329;  treatment 
330;  catarrh  or  oz^na,  383;  treatment, 
385;  deformity  and  its  relief,  402;  hy- 
pertrophy of  mucous  membrane,  370; 
passages,  325;  obstruction,  351;  poly- 
pus, 352;  symptoms,  353;  treatment, 
355;  partial  repair,  420;  deflection  of 
septum,  346;  treatment,  347,  349;  ne- 
crosis of  osseous  septum,  351;  perfora- 
tion of,  400;  tumors  of,  348 

Neck,  800;  surgical  anatomy  of,  800, 
823;  angioma  in,  869;  treatment,  870; 
blood  cysts  on,  871;  treatment,  873; 
carbuncle,  anthrax  on,  893;  congenital 
clefts,  or  fistula  in,  819;  foreign  bod- 
ies in  air  passages,  955;  solid  growths 
of,  873;  hanging,  925,  929;  fracture  of 
hyoid  bone,  922;  treatment,  923; 
larynx,  fracture  of,  923;  symptoms; 
treatment,  924;  lymph-angioma  in, 
867;  malignant  lymphoma  of,  877; 
phlegmon  and  abscess  of,  853;  malig- 
nant pustule  on,  900;  sarcoma  of  cer- 
vical glands,  874;  torticollis,  804; 
treatment,  808;  thvroid  gland,  823; 
tumors  of,  864;  treatment,  867.  880; 
vessels  of,  1096;  wounds  of,  905;  treat- 
ment, 915 

Necrosis,  of  lower  jaw,  738;  prognosis, 
treatment,  741 ;  phosphorus-necrosis, 
743;  treatment,  746;  of  osseous  sep- 
tum, 351 

Nelaton,  on  nasal  defect,  422;  hare-lip, 
568;  luxation  of  inferior  maxilla,  771; 
fibrous  polypus,  360;  sound,  182;  ex- 
cision of  tongue,  634;  tracheotomy, 
1029;  maxilla,  dental  cj'stie  tumors  of, 
749;  wounds  of  neck,  918;  wounds  of 
cranium,  182 

Neoplasms,  pharyngeal  and  oesophageal, 
989 

Nerves  of  scalp,  12 

Neucourt,  on  facial  neuralgia,  785 

Neudorfer,  on  hare-lip,  565;  tracheo- 
tomy, 1021 

Neuralgia,  facial,  783;  of  scalp,  14 

Northrop,  on  laryngotomy,  1080,1083 


1176 


INDKX. 


Nose  and  nasal  passacjes,  325;  angioma 
in,  330;  treatment,  337;  defects  of, 
327;  fracture  of  nasal  bones,  329; 
treatment,  330;  growths  on  external 
surface  of  nose,  334;  injury  of,  327; 
lupus  in,  338;  treatment,  339;  lupus 
rodens,  341;  treatment,  342;  obstruc- 
tion of,  351;  parasites  in,  882 

IXostrils  and  their  diseases,  343;  alar 
margin  defect  of,  421;  bleeding  from 
nose,  371;  treatment,  376;  defect  from 
loss  of  side  of  nose,  421;  deformity  of, 
402;  foreign  bodies  in,  380;  hypertro- 
phy of  nasal  mucous  membranes,  370; 
narrowness  of,  343;  necrosis  of  osseous 
septum,  351;  ozaena,  or  nasal  catarrh, 
383;  treatment,  385;  parasites  in,  382; 
polypus  in,  352;  symptoms,  353; 
treatment,  355;  fibrous  polypus  in. 
360;  treatment.  364;  deflection  of  na- 
sal septum,  346;  treatment,  347; 
tumors  of  nasal  septum,  348;  treat- 
ment, 349 

Nunneley,  on  malignant  growths  of  the 
tongue,  634 

Nussbaum,  on  neurectomy,  702 


o 


Obstruction  of  nasal  passages,  351 

Occlusion  of  auditory  canal,  300;  treat- 
ment, 301;  by  cerumen,  foreign  bodies 
301 

Odontoma,  of  maxilla  inferior,  752; 
treatment,  753 

O'Dwyer,  on  larj-ngotomy,  1079 

Oedema,  14 

(Esophageal  neoplasms,  989;  tracheot- 
omy, bronchotomy,  1000 

CEsophagus,  959;  foreign  bodies  in.  982; 
congenital  defects  of,  961;  malignant 
growths  in,  992;  warts,  cysts,  and 
polypoid  growths  in,  991;  spasms  of, 
971;  treatment,  974;  stricture  of,  963; 
wounds  of,  998 

O'Ferral,  on  carbuncle,  898 

Ogston,  on  congenital  deformity  of  max- 
illa inferior,  733 

Oilier,  on  fibrous  polypus,  366 

Operation,  <if  laryngotomy,  1075;  laryn- 
gectomv,  1086;  in  parotideau  region 
526 

Oppenheimer,on  facial  neuralgia,  786 

Oral  cavity  and  mouth,  lip.--,  544;  roof 
of,  644;  opening,  deviation  of,  552 

Osseous  septum  of  nose,  necrosis  of,  351 

Osteoma,  of  maxilla  inferior,  755;  of 
membranes  of  brain,  218 

Othiematoma  of  ear,  291;  treatment,  293 

Otis,  on  gunshot  wounds  of  cranium,  177 

07,a?na,  or  nasal  catarrh,  383;  treatment, 
385 

O/.enne,  on  cystic  growths  of  tongue, 
625 


Pachj-meningitis,  212;  treatment,  214; 
external,  of  puerperal  origin,  215 

Pacini,  on  insutllation,  937;  on  tracheal 
aspiration,  942 

Paget,  Sir  James,  on  carbuncle,  899; 
cerebral  concussion,  225;  growths  on 
scalp,  124;  excision  of  tongue,  635; 
ulceration  of  tongue,  619;  trephining, 
189 

Palate,  destniction  of  soft,  657;  malfor- 
mations of  soft  and  hard,  652;  treat- 
ment, 653;  staphylorraphy  of,  665; 
tumors  arising  from,  650;  uranoplastv 
of,  677;  wounds  of,  649 

Palatal  structures,  adhesion  of,  656;  cleft 
of,  659;  treatment,  663;  inflammation 
of,  647;  treatment,  648 

Palpebral,  deformities,  473;  treatment, 
473;  narrowness  of  opening,  475;  treat- 
ment, 475 

Pamard,  on  diseases  of  eyelid,  499 

Pancoast,  on  neurectomy,  795 

Pappanheim,  on  tonsillotomy.  702 

Parasites,  in  nasal  passages,  382 

Parasitic  tumors,  219 

Paravini,  on  neurectomy,  792 

Par6  Ambrose,  on  ranula  of  sublingual 
region,  729;  trepan,  201;  wounds  of 
cranium  155,  158;  wounds  of  neck, 
917 

Parise,  of  Lille,  on  hare-lip,  562 

Parotidean  region,  509;  angioma  in,  517: 
treatment,  518;  carcinoma  in,  523; 
epithelioma  in,  522;  fistula  in,  528; 
treatment,  529;  operation  in,  526; 
parotidean  growths,  515;  inflamma- 
tory aft'ections  of  parotid  gland,  521; 
salivary  concretion,  516;  treatment, 
517;  surgeiy  of,  503,  509;  benign  tu- 
mors, 517 

Parotid  gland,  inflammatory  aflections 
of,  513;  treatment,  514;  malignant 
growths  of,  521 

Parotis,  malignant  tumors  of,  523;  treat- 
ment, 523 

Parotitis,  513;  treatment,  514 

Parrot,  on  epithelioma,  218 

Passavant,  on  gunshot  wounds,  183; 
staphylorraphy, 675;  tracheotomy,  1021 

Pasteur,  on  pathology,  25;  malignant 
pustule,  901 

Pathology,  23;  cellular,  24 

Patruban,  on  goitre,  839 

Paul,  of  ^gina,  on  foreign  bodies  in 
auditory  canal,  305 

Paul,  of  Breslau,  on  palatal  adhesion, 
656 

Pauli,  on  ranula,  729;  tracheotomy,  1022 

Periat,  on  hare-lip,  564 

Pericranium,  and  its  atfections,  147;  per- 
iostitis, 148;   wounds  of,  147 

Periostitis,  alveolar,  733 

Petel,  on  tracheotomv,  1017,  1032 


INDEX. 


1177 


Peter,  on  tracheotomy,  1029 

Petit,  on  angioma,  108 

Petrali,  on  torticollis,  814 

P^trequin,  on  ranula,  729 

Pfaif,  on  facial  neuralgia,  788 

Pharj'-ngeal,  tumors,  721;  neoplasms, 
989;  treatment,  990 

Pharynx,  713;  abscess  of,  713;  treatment, 
716;  foreign  bodies  in,  723,  982;  ma- 
lignant growths  in,  992;  ulceration  of, 
719;  treatment,  720 

Philippe,  on  torticollis,  811 

Phlegmon  and  abscess  of  neck,  853; 
treatment,  858;  drainage,  860 

Phosphorus-necrosis  of  lower  jaw,  743; 
treatment,  746        , 

Physic,  on  carbuncle,  896;  fracture  of 
lower  jaw,  780 

Picard,  on  wounds  of  internal  jugular 
vein,  1188 

Pigment  marks,  120 

Pinna,  adherent,  293 

Pisani,  on  ranula,  729 

Pitha,on  maxillary  excision, 763;  staphy- 
lorraphy,  674;  tracheotomy,  1020 

Plastic  surgery,  elements  of,  427;  first 
method,  immediate,  480;  second  meth- 
od, adductive  approximation  by  dis- 
secting, 433;  third  method  circum- 
duction of  pedicled  flap,  440;  other 
methods,  445;  care  of  wounds,  447 

Pneumatocephalus,  emphysema,  from 
middle  ear,  311;  treatment,  312;  of 
eyelids,  469;  in  scalp,  145 

Podrazky,  of  Vienna,  on  excision  of 
tongue,  635 

Poinsot,  on  mastoid  cavity,  309,  310 

Poiseuille,  on  wounds  of  internal  jugular 
vein,  1137 

Polypus,  in  auditory  canal,  301;  fibrous, 
360;  treatment,  364;  in  nose,  352; 
symptoms,  353;  treatment,  355;  poly- 
poid growths  in  cesophagus,  991 

Ponfick,  on  erysipelas,  42 

Porta,  on  goitre,  839;  luxation  of  cervi- 
cal vertebrae,  1146 

Porter,  of  Dublin,  on  tracheotomy,  1027 

Potter,  fracture  of  vertebra3,  1163 

Prichard,  on  carbuncle,  894,  897 

Primitive  carotid,  ligation  of,  1011,  1120 

Prochasky,  on  sneezing,  645 

Prolapsus,  lingual,  with  hypertrophy, 
610 

Psammona,  219 

Pus,  29 

Pustule,  malignant,  on  neck,  900;  path- 
ological changes  after  death,  902;  treat- 
ment, 902 


Quinart,  on  phlegmon  and  abscess,  858 
R 

Kamsden.  on  subclavian  artery    1128 
Pvanula,  727 


Eanvier,  26;  on  epithelioma  of  men- 
inges, 218 

Kanke,  on  anchylosis,  769;  laryngot- 
omy,  1085  "     '" 

Kecamier,  on  cervical  glandular  tu- 
mors, 884 

Eeel-Ogez,  on  tonsillitis,  697 

Region,  sublingual,  725 

Regnoli,  on  malignant  growths  of 
tongue,  633 

Reid,  on  nasal  defects,  423 

Remak,  on  torticollis,  809 

Rents,  fissures,  and  defects  of  external 
ear,  297 

Resection  of  upper  jaw,  536 

Respiration,  artificial,  935;  tracheal  as- 
piration, 938 

Reverdin,  J.  L.,  on  goitre,  845;  plastic 
surgery,  449 

Rhinoplasty,  406 

Richet,  on  ankyloblepharon,  476;  car- 
buncle, 895;  facial  neuralgia,  790; 
surgery  of  frontal  region,  320 

Richter,  on  stricture  of  cesophagus,  979 

Ricord,  on  surgery  of  scalp,  12 

Rigby,  on  carbuncle,  896 

Rizzoli,  on  anchylosis,  769 

Robsen,  Mayo,  on  defects  of  spinal  col- 
umn, 1142 

Rodens,  lupus  or  rodent  ulcer,  341; 
treatment,  342 

Rodent  ulcer,  341;  treatment,  842 

Rokitansky,  on  goitre,  837 

Ronhuysen,  on  torticollis,  810 

Roof  of  oral  cavity,  644 

Rose,  on  goitre,    830;  neurectomy, 

Eoser,  on  gunshot  wounds,  183;  neurec- 
tomy, 793;  tracheotomy,  1023 

Rotter,  on  goitre,  845 

Roustam,  on  pharyngeal  abscess,  716 

Roux,  on  palatal  cleft,  664,  667;  hare- 
lip, 558,  563,  580,  neurectomy,  790; 
trephining,  200;  uranoplasty,  677; 
wounds  of  neck,  916,  922 

Ruppaner,  on  hypertrophy  of  tonsil,  701 

Ryba,  on  orbital  tumor,  497 


Sabatier,  on  wounds  of  neck,  917 
Salivary  concretion,  516;  treatment,  517 
Salter,  on  facial  neuralgia,  786 
Sanctorius,  of  Padua,  on  tracheotomy, 

bronchotomy,  1001 
Sanguineous  tumor,  infantile,  119 
Sarazin,  on  fistulaB  of  neck,  823 
Sarcoma,  of  neck,  874 
Scalp,    atfections  of,  14;  surgical   anat- 
omy of,   7;  angioma  in,  103;  arteries 
of,  10;  atrophy  of,  89;  carcinoma  in 
139;  contusion  of,  65;  cystoma  in,  93 
epithelioma  of,  131;  erysipelas  of,  38 
gangrene  of,   82;  malignant  growths 
in,  121;  vascular  growths  in,  114;  hy- 
pertrophy of,  88;  inflammation  of,  14; 
lipoma  in,  99;  lymphatic  vessels  and 


75 


1178 


INDEX. 


glands  of,  11;  nerves  of,    12;  pcrici-;i- 
iiiuni,   147;  pigment  murks    on,   120; 

?neumatocephulus  of,  145;  surgery  of, 
;  trephination,  185;  tumors  oi", 89;  in- 
fantile sanguineous  tumor  on,  119; 
ulceration  of,  85;  warts  in,  91; 
wounds  of,  49,  147;  gunshot  wounds 
of,  75;  wounds,  treatments  of,  78 

Scarification,  47 

Schaefer,  Max,  on  ozaena,  384,  386 

Schillbach,  on  maxillary  excision,  702; 
trephining  over  frontal  sinus,  324 

Schmidt,  on  anchj'losis,  767;  narrow 
nostrils,  344 

Schijuborn,  on  uranoplasty,  682;  ceso])li- 
ageal  neoplasms,  998 

Schramm,  on  facial  neuralgia,  786 

Schuh,  on  neurectomy,  791 

Schiiller,  on  aspiration,  943;  laryngot- 
omy,  1076;  tracheotomy,  1008  " 

Schulten,  on  anchylosis,  765 

Schultze,  on  artificial  breathing,  943 

Schuster,  on  malignant  lymphoma,  883 

Schiitzenberger,  on  scarification,  47 

Schwabach,  on  external  ear,  288 

Schwalte,  on  goitre,  837 

Scrofulous  ulcer,  in  cheek,  508;  trosit- 
ment,  509 

Sedillot,  on  laTjial  cancer,  602;  goitre, 
840;  malignant  growths,  634;  hare- 
lip, 568;  staphylorraphy,  673;  trephin- 
ation, 193 

See,  16;  on  carbuncle,  898 

Second  method  in  plastic  surgery,  433 

Septum  nasal,  deflection  of,  346;  treat- 
ment, 347;  necrosis  of  osseous,  351; 
perforation  of,  400;  tumors  of,  348; 
treatment,  349 

Serre,  on  atresia  of  mouth,  549 

Sestier,  on  tracheotomy,  1018 

Severini,  on  tonsillotomy,  702 

Sharp,  on  tonsillotomy,  702 

Shillitoe,  on  carbuncle,  896 

Sichel,  on  orbital  melanoma,  400 

Simon,  on  thermo-electric  test  of  in- 
crease of  heat,  18;  tracheotomy,  1027; 
wounds  of  jugular  vein,  ''136;  gunshot 
wounds,  175 

Sinus,  frontal, 318;  trephining  over,  323; 
maxillary,  301 

Skull,  gunshot  wounds  of,  75 

Smith,  on  lymph-angioma,  869;  palatal 
malformations,  653,  668;  luxation  of 
cervical  vertebrae,  1144 

Smyly,  on  staphylorraphy,  673 

Socin,  on  goitre,  841 

Soupart,  of  Ghent,  on  hare-lip,  583 

South,  on  wounds  of  neck,  918;  phar- 
ynx and  oesophagus,  982 

Spasm,  of  oesophagus,  963 

Spessa,  on  staphylorraphy,  665 

Spinal  column,  congenital  defects  of, 
1139;  treatment;  fUl 

Sprengler,  on  anchylosis,  768;  excision 
of  lower  jaw,  764 


Springer,  on  maxillary  resection,  541 

Stahl,  22 

Staphylorraphy  of  palate,  665;  authori- 
ties cited  in  treatment,  673 

Startin,  on  carbuncle,  806 

Steiger,  on  ccsoj)hageal  stricture,  063 

Steiner,  on  tracheotomy,  1029 

Steinlein.  on  luxation  of  inferior  max- 
illa, 771 

St.  Germain,  on  phlegmon  and  abscess, 
860;  tumor  of  brain,  270;  tonsillot- 
omy, 704;  tracheotomy,  1046 

St.  Lager,  on  orbital  tumor,  499 

Strangulation,  hanging,  925;  artificial 
respiration,  935;  insufflation,  935 

Streatfield,  on  entrypion,  489 

Strieker,  16 

Stricture,  of  oesophagus,  963 

Stromeyer,  on  facial  neuralgia,  784;  on 
tonsillitis,  696;  on  torticollis,  816; 
on  trephination,  194 

Sty,  hordeolum  or  acne  ciliaris,  471; 
treatment,  471 

Subclavian  artery,  1127 

Sublingual  region,    725;  ranula  of,  727 

Suppuration,  inflammatory,  29 

Surgery,  of  external  ear,  285;  of  frontal 
region,  315;  treatment,  315;  i)lasiic, 
427;  of  malar  and  parotidean  regions 
of  face,  503;  of  scalp,  7 

Surgical,  affections,  of  eyebrows  and 
eyelids,  455;  anatomy  of  neck,  800; 
frontal  region,  315;  of  membranes  of 
brain,  209;  of  maxilla  inferior,  732; 
of  scalp,  7.;  of  thyroid  gland,  823;  of 
tongue,  607;  of  tonsil,  686 

Symblepharon,  or  bulbo-palpebral  un- 
ion, 476;  treatment,  477 

Syme,  on  excision  of  maxilla  inferior, 
760;  lingual  prolapsus,  612;  excision 
of  tongue,  634 

Syphilis,   149 

Syphiloma,  in  brain,  262;  treatment, 
267;  in  membrane  of  brain,  220 

Szymanowsky,  on  ectropion,  481 


Tait,  Lawson,  on  phlegmon  and  abscess, 
859 

Tagliacozzi,  418 

Taliacotius,  on  rhinoplasty,  407,  418 

Tardieu,  on  strangulation,  927 

Tarsal,  tumor,  of  eyelid,  471;  treatment, 
472 

Taylor,  on  hanging,  031;  drowning,  947 

Tazon,  on  gunshot  wounds  of  cranium, 
173 

Teale,  on  labial  hypertrophy,  555;  sym- 
blepharon, 477 

Teeth,  wisdom,  ill  placed  763;  treat- 
ment, 738 

Teevan,  of  London,  on  gunshot  wounds 
of  cranium,  173 

Textor,  on  orbital  tumor,  495 


INDEX. 


1179 


Thierry,  on  hare-lip,  566 

Thiersch,  on  lingual  epithelioma,  634; 
.method  of  dermal  transplantation, 
449,  450;  uranoplasty,  682 

Third  method  in  plastic  surgeiy,  440 

Thomas,  of  Tours,  on  pneumatocephalus, 
312 

Thompson,  on  tracheotomy,  1019 

Thudicum,  on  nasal  polypus,  359 

Thyroid  gland, surgical  anatomy  of,  823; 
aifeetions  ef,  823;  goitre,  825;  medi- 
cal treatment,  835;  surgical  treat- 
ment, 838;  exophthalmic  goitre,  847; 
malignant  disease  of,  849;  thyroiditis, 
851;  wounds  of,  850 

Thyroiditis,  851 

Tillaux,  8,  18;  on  aflections  of  auditory 
canal,  298;  foreign  bodies  in  auditory 
canal,  306;  haemorrhage  from  audi- 
tory passage,  850;  external  ear,  286, 
mastoid  cavity  of  ear.  308,  310;  goitre, 
829;  parotidean  fistula,  530;  atfections 
of  parotid  gland,  513 

Tongue,  607;  abscess  of,  618;  surgical 
anatomy  of,  607-  aneurism^  650; 
ankyloglossa,  or  tongue-tie,  613;  de- 
formities of,  609-  fibroma  of,  626; 
foreign  bodies  in,  644;  growths  of, 
622;  treatment,  623;  cystic  growths  of, 
G24;  malignant  growths  of,  626;  diag- 
nosis, 631;  treatment,  633;  inflam- 
mation of,  or  glossitis,  615;  treatment, 
617;  lingual  prolapsus  with  hyper- 
trophy, 610 

Tongue-tie,  or  ankyloglossa,  Cicero  on, 
613 

Tonsil,  686;  surgical  anatomy  of,  686; 
hypertrophy  of,  697;  ti-eatment,  700; 
tonsillitis,  688;  tonsillotomy,  or  ex- 
cision of  tonsils,  701 

Tonsillar  tumors,  710;  treatment,  711 

Tonsillitis,  688;  treatment,  694 

Tonsillotomy,  amygdalotomy  or  ex- 
cision of  tonsils,  701 

Torticollis,  804;  treatment,  808 

Toynbee,  on  encephalitis,  251 

Tracheotomy,  1000 

Transplantation,  Thiersch's  method  of 
skin  grafting   449 

Traumatic  lesions  of  cranium,  153 

Trelat,  on  carbuncle,  898;  hart:-Mp,  562; 
phosphorus-necrosis.  747;  staphylorra- 
phy,  675;  ulceration  of  tongue,  620; 
tracheotomy,  1010 

Trephination,  authorities  cited,  188,  191; 
conditions  which  favor  or  contraindi- 
cate,  242;  over  frontal  sinus,  323 

Tricot,  on  hare-lip,  566,  567 

Trousseau,  on  facial  neuralgia,  786; 
laryngotomy,  1079;  o;^ffina,  383,  386; 
tracheotomy,  1017,  1022,  1044,  1051, 
1055 

Tubercle,  on  membrane  of  brain,  220 

Tulpius,  on  ranula,  729 

Ttirck,  on  facial  neuralgia,  789 


Tumors,    benign,   517;    in   brain,     261; 

■symptoms,  263;  treatment,  267;  con- 
stitutional, 219;  cervical  glandular, 
880;  of  dura  mater,  216;  epithelioma, 
218;  of  eyelid,  tarsal,  gelatinous  or 
fibrinous,  471;  treatment,  472;  of 
maxillary  sinus,  398;  maxillo-dental, 
cystic,  748;  treatment,  752;  meningeal, 
effects  of,  220;  treatment,  221;  of  neck, 
864;  treatment,  867,  495;  osteoma, 
218;  from  palate,  650;  tumors  in  par- 
otidean region,  517;  of  parotis,  523; 
treatment,  523;  parasitic,  219;  phar- 
yngeal, 721;  psammona,  219;  infantile 
sanguineous,  119;  of  scalp,  89;  ton- 
sillar, 710;  treatment,  711 


u 


Ulcer,  scrofulous,   in  cheek,  508;  treat- 
ment,   509;    rodent,    341;    treatment 
342 

Ulceration,  inflammatory,  33;  of  phar- 
ynx, 719;  treatment,  720;  of  scalp, 
85;  of  tongue,  618;  treatment,  620 

Upper  jaw,  resection  of,  536 

Uranoplasty,  677 

Uspensky,  on  facial  neuralgia,  783 

Uvula  and  soft  palate,  destruction  of, 
657 

Uterhart,  on  wounds  in  internal  jugular 
vein.  1138 


Valentin,  on  stricture  of  oesophagus,  979 

Van  der  Haar,  on  lingual  px'olapsus,  612 

Van  Helmont,  22 

Van  Swieten,  on  trephining,  243 

Vascular  growths,  in  scalp,  114 

Velpeau,  on  carbuncle,  898;  external 
ear,  288;  narrow  nostrils,  345;  phleg- 
mon and  abscess,  858;  rhinoplasty, 
415;  trephination,  195;  cervical  glan- 
dular tumors,  884 

Verneuil,  on  anchylosis,  768;  concussion 
of  brain,  223;  carbuncle,  898;  erysip- 
elas, 42;  excision  of  lower  jaw,  762; 
malignant  lymphoma,  883;  ozjena, 
390;  oesophageal  neoplasms,  998; 
fibrous  polypus,  366;  ranula,  731; 
retro-pharyngeal  abscess,  714;  rhino- 
plasty, 416;  tonsillitis,  693;  cej-vical 
glandular  tumors,  884 

Vertebra,  cervical,  luxation  of,  1144; 
fracture  of,  1150 

Vesalius,  on  pathology,  23 

Vesication,  47 

Vessels  of  neck,  1096 

Viborg,  on  parotidean  fistttla,  552 

Virchow,  24;  on  cancer,  140;  inflam- 
mation, 37;  otha?matoma,  292;  paroti- 
tis, 513,  514;  psammona,  219;  orbital 
tumors,  497 

Vogel,  on  goitre,  839 


1180 


INDEX. 


Voillemier,  on   phlegmon  and   abscess, 

8u!t 
Volkniann,  on  excision  of  tongue,  638; 

torticollis,  814 
Von  Amnion,  on  ankyloblepharon,  476; 

on    ectropion,     481;    entropion,    487; 

torticollis,  805 
Yon  Walter,  on  goitre,  840 
Yulpian,  190 

w 

Wadsworth,  on  ectropit>n,  486 
Wagner,  on  luxation  of  cervical  verte- 
bra, 1147 
Walsham,  on  trephination,  198 
Walther,  palpebral  deformities,  473 
Warren,  on  staphylorraphy,  *i73 
Warts,  in  scalp,  91;  in  (esophagus,  991 
Watson,  on  ozwna,  384,  387 
Wattmann,  on  wounds  of  internal  jugu- 
lar vein,  1136 
Waxham.  on  laryngotomv,  1084 
Weber,    Otto,  on  labial  cancer,  603;  la- 
bial entropion,  555;  inflammation,  16, 
26;  test  for  inflammation,   19;  inaxil- 
larv  resection,  54-;  maxilla  superior, 
537;  parotidean  tumors,  526;  ulcer  of 
tongue,  620 
Weinlechner,  on  laryngotomv,  1079 
Weintrach,    on    occlusion    of    auditory 

canal,  300 
Weiss,  on  othsematoma,  291 
Wegner,  on  extirpation  of  larynx,  1089 
Wells,  on  entropion,  489 
Whitehead,  on  excision  of  tongue,  636 
Wilde's  snare,  301 

Wilm«,   of  Berlin,  on  anchylosis,  768; 
tracheotomy,  1030 


Winiwarter,  on  cervical  glandular  tu- 
mors, 882 

Wisdom  teeth,  ill  placed,  736;  treatment 
738 

Wiseman,  on  carbuncle,  898;  on  tonsil- 
lotomy, 702 

Witkowsky,  on  cerebral  concussion,  226 

Woakes,  on  hare-lip,  566 

AViJlfler,  on  goitre,  839,  841;  on  excision 
of  tongue,'637 

Wolzendorf,  on  wounds  of  oesophagus, 
999 

Worner,  on  labial  cancer,  598;  on  goitre, 
840 

Wounds,  of  cheek  and  side  of  face,  504; 
contusion,  65;  of  cranium,  172;  in- 
cised, of  cranium,  157;  of  ear,  290;  of 
eyelids,  463;  of  thyroid  gland,  850; 
gunshot,  general  remarks,  72;  wounds 
of  neck,  905;  treatment,  915;  of 
oesophagus,  998;  of  palate,  649;  of 
pericranium,  147;  of  scalp  and  skull, 
V'5;  of  scalp,  49,  147;  of  tongue,  64;!; 
of  jugular  vein,  1132 

Wut/.cr,  on  labial  cancer,  601;  lingual 
prolapsus,  612;  uranoplasty,  677 


Zaufal,  on  ozwna,  384 

Zauii',  on  ligation  of  primitive  carotid, 

1112 
Zenker,  on  oesophageal  neoplasms,  992 
Ziemssen,   on    tracheal   aspiration,   945; 
extirpation  of  larynx,    1089;  oesopha- 
geal neoplasms,  994 
Zimmerlin,  on  tracheotomy,  1032 
Zuckerkandl,  on  tumors  of  neck,  866 


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